Provider Demographics
NPI:1184087694
Name:EVENING TIDE OF BREVARD, LLC
Entity type:Organization
Organization Name:EVENING TIDE OF BREVARD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:NA
Authorized Official - Phone:435-760-4091
Mailing Address - Street 1:100 N ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2915
Mailing Address - Country:US
Mailing Address - Phone:321-613-4569
Mailing Address - Fax:321-613-0217
Practice Address - Street 1:100 N ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2915
Practice Address - Country:US
Practice Address - Phone:321-613-4569
Practice Address - Fax:321-613-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health