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General NPI Number Information
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NPI Number | 1629880711
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Entity Type | Organization
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Legal Business Name | PEDIATRIC HEALTH & WELLNESS OF BREVARD, PA
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Dates
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Enumeration Date | 01/24/2025
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Last Update Date | 01/24/2025
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Provider Practice Location Address
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Address Line | 3000 N WICKHAM RD STE 5
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City | MELBOURNE
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State | FL
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Zip | 32935-2330
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Country | US
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Telephone | 321-652-2381
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Fax |
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Provider Business Mailing Address
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Address Line | 4355 LAKEMONT RD
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City | MELBOURNE
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State | FL
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Zip | 32934-7731
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Country | US
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Telephone | 321-652-2381
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KIMBERLY M MARTIN
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Credential | APRN
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Telephone | 321-652-2381
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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