Provider Demographics
NPI:1174674956
Name:BREVARD HEALTH ALLIANCE
Entity Type:Organization
Organization Name:BREVARD HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:VENDETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-722-5970
Mailing Address - Street 1:5270 BABCOCK ST NE # ST1
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-8630
Mailing Address - Country:US
Mailing Address - Phone:321-722-5973
Mailing Address - Fax:
Practice Address - Street 1:5270 BABCOCK ST NE # ST1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-8630
Practice Address - Country:US
Practice Address - Phone:321-722-5973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-1975Medicare ID - Type Unspecified