MEDICARE: BREVARD HEALTH ALLIANCE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134276074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREVARD HEALTH ALLIANCE INC

Provider Business Mailing Address
First Line	:	220 BARTON BLVD
Second Line	:	UNIT #C14
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-2742
Country	:	US
Telephone Number	:	321-639-5177
Fax Number	:	321-639-4927

Provider Business Practice Location Address
First Line	:	220 BARTON BLVD
Second Line	:	UNIT #C14
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-2742
Country	:	US
Telephone Number	:	321-639-5177
Fax Number	:	321-639-4927

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	ANGELA CRAIG
Credential	:
Telephone Number	:	321-952-9696

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	02/18/2014

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Directions to “BREVARD HEALTH ALLIANCE INC ” Practice Location

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