Basic Information
Provider Information | |||||||||
NPI: | 1902214588 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANCER CARE CENTERS OF BREVARD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1048 HARVIN WAY | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 32955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216362111 | ||||||||
FaxNumber: | 3216367180 | ||||||||
Practice Location | |||||||||
Address1: | 1048 HARVIN WAY | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 32955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216362111 | ||||||||
FaxNumber: | 3216367180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2014 | ||||||||
LastUpdateDate: | 08/31/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ERENTREICH | ||||||||
AuthorizedOfficialFirstName: | GAIL | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL SERVICES | ||||||||
AuthorizedOfficialTelephone: | 3216362111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/31/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 64498 | FL | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
ID Information
ID | Type | State | Issuer | Description | 39835 | 01 | FL | GROUP MEDICARE | OTHER | 265641800 | 05 | FL |   | MEDICAID |