Healthcare Provider Details

I. General information

NPI: 1164807749
Provider Name (Legal Business Name): NUEVA VIDA BEHAVIOR CENTER OF TAMPA,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E SLIGH AVE
TAMPA FL
33604
US

IV. Provider business mailing address

215 E SLIGH AVE
TAMPA FL
33604-5547
US

V. Phone/Fax

Practice location:
  • Phone: 813-626-5690
  • Fax: 813-621-4285
Mailing address:
  • Phone: 813-626-5690
  • Fax: 813-621-4285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIE C FLORES
Title or Position: CEO
Credential:
Phone: 813-626-5690