Provider Demographics
NPI:1972388445
Name:BRAVE ESSENTIALS LLC
Entity type:Organization
Organization Name:BRAVE ESSENTIALS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-922-3553
Mailing Address - Street 1:3322 SAINT VINCENT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1338
Mailing Address - Country:US
Mailing Address - Phone:314-922-3553
Mailing Address - Fax:
Practice Address - Street 1:6018 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-1402
Practice Address - Country:US
Practice Address - Phone:314-915-9740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier