Healthcare Provider Details

I. General information

NPI: 1679228027
Provider Name (Legal Business Name): COMMUNITY ACCESS TO CHILD HEALTH OF BREVARD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1264 US HIGHWAY 1 STE 103
ROCKLEDGE FL
32955-2746
US

IV. Provider business mailing address

1264 US HIGHWAY 1 STE 103
ROCKLEDGE FL
32955-2746
US

V. Phone/Fax

Practice location:
  • Phone: 321-634-3688
  • Fax: 321-504-0955
Mailing address:
  • Phone: 321-634-3688
  • Fax: 321-504-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: LISA KAY GEMMILL
Title or Position: HR MANAGER
Credential:
Phone: 321-634-3688