1184398380 NPI number — BREVARD HEALTH ALLIANCE INC

Table of content: (NPI 1184398380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184398380 NPI number — BREVARD HEALTH ALLIANCE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREVARD HEALTH ALLIANCE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184398380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1137
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32902-1137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-952-9696
Provider Business Mailing Address Fax Number:
321-952-7937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 GRANT STREET
Provider Second Line Business Practice Location Address:
SUITE 137
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-334-6940
Provider Business Practice Location Address Fax Number:
321-334-6912
Provider Enumeration Date:
08/03/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CRAIG
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BILLING
Authorized Official Telephone Number:
321-241-6834

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 688693128 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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