1467551762 NPI number — CANCER CARE CENTERS OF BREVARD INC

Table of content: (NPI 1467551762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467551762 NPI number — CANCER CARE CENTERS OF BREVARD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANCER CARE CENTERS OF BREVARD 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:
1467551762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100045
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30348-0045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-952-0898
Provider Business Mailing Address Fax Number:
321-952-6296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1430 S. PINE ST.
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:
32901-3119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-952-0898
Provider Business Practice Location Address Fax Number:
321-952-6296
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHARLES
Authorized Official First Name:
SILAS
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-952-0898

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 372996619 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996601 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996602 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996604 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996606 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996618 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996605 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL7578 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 372996603 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996620 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 372996623 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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