Provider Demographics
NPI:1164017224
Name:MURO BORREGO, PAVEL MANUEL
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:MANUEL
Last Name:MURO BORREGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7222 N CHURCH AVE APT B
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2608
Mailing Address - Country:US
Mailing Address - Phone:281-802-4513
Mailing Address - Fax:
Practice Address - Street 1:7222 N CHURCH AVE APT B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2608
Practice Address - Country:US
Practice Address - Phone:281-802-4513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-148440106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty