MEDICARE: ENLIGHTEN BEHAVIORAL HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1699348516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENLIGHTEN BEHAVIORAL HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	10810 BOYETTE RD # 3341
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-8000
Country	:	US
Telephone Number	:	813-300-2846
Fax Number	:

Provider Business Practice Location Address
First Line	:	10810 BOYETTE RD # 3341
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-8000
Country	:	US
Telephone Number	:	813-300-2846
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICKORIA SMITH
Credential	:
Telephone Number	:	813-300-2846

Provider Enumeration Date	:	07/19/2021
Last Update Date	:	07/19/2021

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