Provider Demographics
NPI:1720279458
Name:ALLIANCE HEALTHCARE GROUP
Entity Type:Organization
Organization Name:ALLIANCE HEALTHCARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RAJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:321-951-7404
Mailing Address - Street 1:20 E MELBOURNE AVE
Mailing Address - Street 2:104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5970
Mailing Address - Country:US
Mailing Address - Phone:321-951-7404
Mailing Address - Fax:
Practice Address - Street 1:20 E MELBOURNE AVE
Practice Address - Street 2:104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5970
Practice Address - Country:US
Practice Address - Phone:321-951-7404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMPREHENSIVE MEDIICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL500016OtherAHCA NUMBER