Basic Information
| Provider Information | |||||||||
| NPI: | 1801561709 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANCER CARE CENTERS OF BREVARD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1048 HARVIN WAY | ||||||||
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| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1321636211 | ||||||||
| FaxNumber: | 3216367180 | ||||||||
| Practice Location | |||||||||
| Address1: | 1541 S WICKHAM RD | ||||||||
| Address2: | |||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329043540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217258300 | ||||||||
| FaxNumber: | 3217251555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2021 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | ERENTREICH | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
| AuthorizedOfficialMiddleName: | KNIGHT | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3216362111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.