Basic Information
Provider Information | |||||||||
NPI: | 1841829280 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH BREVARD MEDICAL SUPPORT, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 951 N WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | TITUSVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 327962163 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3212686111 | ||||||||
FaxNumber: | 3212686231 | ||||||||
Practice Location | |||||||||
Address1: | 7075 N US HIGHWAY 1 | ||||||||
Address2: |   | ||||||||
City: | COCOA | ||||||||
State: | FL | ||||||||
PostalCode: | 329275216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3212686111 | ||||||||
FaxNumber: | 3212686231 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2020 | ||||||||
LastUpdateDate: | 04/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MIKITARIAN | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 3212686111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NORTH BREVARD MEDICAL SUPPORT, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PRESIDENT/CEO | ||||||||
NPICertificationDate: | 04/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.