Provider Demographics
NPI:1568887917
Name:BREVARD ALZHEIMER'S FOUNDATION, INC.
Entity Type:Organization
Organization Name:BREVARD ALZHEIMER'S FOUNDATION, INC.
Other - Org Name:JOE'S CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
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:
Practice Address - Street 1:4676 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-7103
Practice Address - Country:US
Practice Address - Phone:253-253-4430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREVARD ALZHEIMER'S FOUNDATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-21
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8856343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6760597000Medicaid