Provider Demographics
NPI:1104121300
Name:THE BREVARD HEALTH ALLIANCE INC
Entity type:Organization
Organization Name:THE BREVARD HEALTH ALLIANCE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-952-9696
Mailing Address - Street 1:705 BLAKE AVE
Mailing Address - Street 2:BLDG G
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7100
Mailing Address - Country:US
Mailing Address - Phone:321-633-6391
Mailing Address - Fax:321-633-6441
Practice Address - Street 1:705 BLAKE AVE
Practice Address - Street 2:BLDG G
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7100
Practice Address - Country:US
Practice Address - Phone:321-633-6391
Practice Address - Fax:321-633-6441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6886931-11Medicaid