Basic Information
| Provider Information | |||||||||
| NPI: | 1790056877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BREVARD HEALTH ALLIANCE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MALABAR CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 775 MALABAR RD | ||||||||
| Address2: | |||||||||
| City: | MALABAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329503120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217228435 | ||||||||
| FaxNumber: | 3217228486 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 MALABAR RD | ||||||||
| Address2: | |||||||||
| City: | MALABAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329503120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217228435 | ||||||||
| FaxNumber: | 3217228486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2012 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3219529696 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 6886931-14 | 05 | FL | MEDICAID |