Healthcare Provider Details

I. General information

NPI: 1992886477
Provider Name (Legal Business Name): CMS ROCKLEDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 JUDGE FRAN JAMIESON WAY
VIERA FL
32940-5998
US

IV. Provider business mailing address

2565 JUDGE FRAN JAMIESON WAY
VIERA FL
32940-5998
US

V. Phone/Fax

Practice location:
  • Phone: 321-639-5888
  • Fax: 321-690-3887
Mailing address:
  • Phone: 321-639-5888
  • Fax: 321-690-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. CATHLEEN MARK
Title or Position: REGIONAL PROGRAM ADMINISTRATOR
Credential:
Phone: 407-858-5579