Provider Demographics
NPI:1235508169
Name:BRITO, MANUEL SR
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:BRITO
Suffix:SR
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 1:10103 BAY WIND CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2634
Mailing Address - Country:US
Mailing Address - Phone:813-443-2222
Mailing Address - Fax:
Practice Address - Street 1:10103 BAY WIND CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2634
Practice Address - Country:US
Practice Address - Phone:813-443-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11790320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness