Healthcare Provider Details

I. General information

NPI: 1902244486
Provider Name (Legal Business Name): BREVARD HEALTH ALLIANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 SARNO RD
MELBOURNE FL
32935-3084
US

IV. Provider business mailing address

PO BOX 1137
MELBOURNE FL
32902-1137
US

V. Phone/Fax

Practice location:
  • Phone: 321-952-9696
  • Fax: 321-952-7937
Mailing address:
  • Phone: 321-952-9696
  • Fax: 321-952-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ANGELA CRAIG
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 321-952-9696