Provider Demographics
NPI:1669082079
Name:BRAZIL, MANNY (RD)
Entity type:Individual
Prefix:
First Name:MANNY
Middle Name:
Last Name:BRAZIL
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 JUNEAU DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-7893
Mailing Address - Country:US
Mailing Address - Phone:707-514-5418
Mailing Address - Fax:
Practice Address - Street 1:233 JUNEAU DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-7893
Practice Address - Country:US
Practice Address - Phone:707-514-5418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-01
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86131716133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered