Provider Demographics
NPI:1043034374
Name:BRAVANTECH INNOVATIONS LLC
Entity type:Organization
Organization Name:BRAVANTECH INNOVATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANI
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-474-6670
Mailing Address - Street 1:2847 S INGRAM MILL RD STE A100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4006
Mailing Address - Country:US
Mailing Address - Phone:747-474-6670
Mailing Address - Fax:
Practice Address - Street 1:2847 S INGRAM MILL RD STE A100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4006
Practice Address - Country:US
Practice Address - Phone:214-705-2301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-13
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies