Healthcare Provider Details

I. General information

NPI: 1174795454
Provider Name (Legal Business Name): BREVARD ALZHEIMER'S FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4676 N WICKHAM RD
MELBOURNE FL
32935-7103
US

IV. Provider business mailing address

4676 N WICKHAM RD
MELBOURNE FL
32935-7103
US

V. Phone/Fax

Practice location:
  • Phone: 321-253-4430
  • Fax: 321-757-6971
Mailing address:
  • Phone: 321-253-4430
  • Fax: 321-253-1993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY VICTOR TIMMERMANN JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 321-253-4430