Provider Demographics
NPI:1215237342
Name:BREVARD ACHIEVEMENT CENTER
Entity type:Organization
Organization Name:BREVARD ACHIEVEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-632-8610
Mailing Address - Street 1:1845 COGSWELL STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-632-8610
Mailing Address - Fax:321-639-5087
Practice Address - Street 1:1845 COGSWELL STREET
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-632-8610
Practice Address - Fax:321-639-5087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024163601Medicaid
FL024163696Medicaid