Healthcare Provider Details

I. General information

NPI: 1023681343
Provider Name (Legal Business Name): CANCER CARE CENTERS OF BREVARD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N WICKHAM RD STE 101
MELBOURNE FL
32935-8663
US

IV. Provider business mailing address

1430 PINE ST
MELBOURNE FL
32901-3119
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-4811
  • Fax: 321-752-4822
Mailing address:
  • Phone: 321-952-0898
  • Fax: 321-722-1342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: GAIL KNIGHT ERENTREICH
Title or Position: DIRECTOR OF CLINICAL OPERATIONS
Credential:
Phone: 321-636-2111