Provider Demographics
NPI:1952451239
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 1:15 ROSA L JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7899
Mailing Address - Country:US
Mailing Address - Phone:321-639-5177
Mailing Address - Fax:
Practice Address - Street 1:15 ROSA L JONES BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7899
Practice Address - Country:US
Practice Address - Phone:321-639-5177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6886931-09Medicaid
FL6886931-09Medicaid