Provider Demographics
NPI:1821552696
Name:SPACE COAST NEPHROLOGY ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:SPACE COAST NEPHROLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-768-3655
Mailing Address - Street 1:111 E HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3102
Mailing Address - Country:US
Mailing Address - Phone:321-768-3655
Mailing Address - Fax:321-831-3024
Practice Address - Street 1:111 E HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3102
Practice Address - Country:US
Practice Address - Phone:321-768-3655
Practice Address - Fax:321-831-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-25
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty