Provider Demographics
NPI:1518633569
Name:BREVARD ALZHEIMER'S FOUNDATION INC.
Entity Type:Organization
Organization Name:BREVARD ALZHEIMER'S FOUNDATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:TIMMEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-253-4430
Mailing Address - Street 1:4676 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-7103
Mailing Address - Country:US
Mailing Address - Phone:321-253-4430
Mailing Address - Fax:321-253-1993
Practice Address - Street 1:830 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4000
Practice Address - Country:US
Practice Address - Phone:321-253-4430
Practice Address - Fax:321-253-1993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104835401Medicaid