1215221221 NPI number — BREVARD ASSISTED LIVING LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215221221 NPI number — BREVARD ASSISTED LIVING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREVARD ASSISTED LIVING LLC
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:
1215221221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9060 S TROPICAL TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32952-6803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-693-4269
Provider Business Mailing Address Fax Number:
321-406-0298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3831 FUNSTON CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-8583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-693-4269
Provider Business Practice Location Address Fax Number:
321-406-0298
Provider Enumeration Date:
06/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MESAROS
Authorized Official First Name:
JOHNNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
321-693-4269

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  11779 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2026 www.npivalidator.com