MEDICARE: BREVARD HEALTH ALLIANCE INC

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1073855797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREVARD HEALTH ALLIANCE INC

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

Provider Business Practice Location Address
First Line	:	4000 N RIVERSIDE DR
Second Line	:
City	:	INDIAN HARBOUR BEACH
State	:	FL
Zip	:	32937-4842
Country	:	US
Telephone Number	:	321-914-5557
Fax Number	:	321-434-1975

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	ANGELA CRAIG
Credential	:
Telephone Number	:	321-952-9696

Provider Enumeration Date	:	03/20/2013
Last Update Date	:	04/01/2013

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Directions to “BREVARD HEALTH ALLIANCE INC ” Practice Location

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