Provider Demographics
NPI:1992886477
Name:CMS ROCKLEDGE
Entity type:Organization
Organization Name:CMS ROCKLEDGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-858-5579
Mailing Address - Street 1:2565 JUDGE FRAN JAMIESON WAY
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-5998
Mailing Address - Country:US
Mailing Address - Phone:321-639-5888
Mailing Address - Fax:321-690-3887
Practice Address - Street 1:2565 JUDGE FRAN JAMIESON WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-5998
Practice Address - Country:US
Practice Address - Phone:321-639-5888
Practice Address - Fax:321-690-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060189600Medicaid