Provider Demographics
NPI:1902214588
Name:CANCER CARE CENTERS OF BREVARD
Entity Type:Organization
Organization Name:CANCER CARE CENTERS OF BREVARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:ERENTREICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-636-2111
Mailing Address - Street 1:1048 HARVIN WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-636-2111
Mailing Address - Fax:321-636-7180
Practice Address - Street 1:1048 HARVIN WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-636-2111
Practice Address - Fax:321-636-7180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL64498332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39835OtherGROUP MEDICARE
FL265641800Medicaid