Healthcare Provider Details

I. General information

NPI: 1609449917
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

1048 HARVIN WAY
ROCKLEDGE FL
32955-3229
US

IV. Provider business mailing address

1430 PINE ST
MELBOURNE FL
32901-3119
US

V. Phone/Fax

Practice location:
  • Phone: 132-163-6211
  • Fax: 321-636-7180
Mailing address:
  • Phone: 321-674-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

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