1356334718 NPI number — SPACE COAST CORPORATE HEALTH SERVICE P A

Table of content: (NPI 1356334718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356334718 NPI number — SPACE COAST CORPORATE HEALTH SERVICE P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPACE COAST CORPORATE HEALTH SERVICE P A
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:
6
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:
1356334718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
145 PALM BAY RD NE
Provider Second Line Business Mailing Address:
STE 120
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32904-8601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-725-8778
Provider Business Mailing Address Fax Number:
321-984-5299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 PALM BAY RD NE
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32904-8601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-725-8778
Provider Business Practice Location Address Fax Number:
321-984-5299
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CLOW
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
JE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-725-8778

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH4422 , 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)

  • Identifier: 34121 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com