Provider Demographics
NPI:1679373237
Name:6574BRAVO LLC
Entity type:Organization
Organization Name:6574BRAVO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:870-416-3555
Mailing Address - Street 1:207 OLD FARM RD S
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-8629
Mailing Address - Country:US
Mailing Address - Phone:870-577-3135
Mailing Address - Fax:
Practice Address - Street 1:1416 HIGHWAY 62 65 N STE C
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-1959
Practice Address - Country:US
Practice Address - Phone:870-416-5555
Practice Address - Fax:870-416-3990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:6574BRAVO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-13
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy