Healthcare Provider Details

I. General information

NPI: 1043634876
Provider Name (Legal Business Name): JUSTIN FAMILY A.L.F. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2014
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10103 BAY WIND CT
TAMPA FL
33615-2634
US

IV. Provider business mailing address

10103 BAY WIND CT
TAMPA FL
33615-2634
US

V. Phone/Fax

Practice location:
  • Phone: 813-735-3600
  • Fax: 813-405-4149
Mailing address:
  • Phone: 813-735-3600
  • Fax: 813-405-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberAL11790
License Number StateFL

VIII. Authorized Official

Name: MANUEL BRITO
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 813-735-3600