NPIMap

Organization Active NPI

Brevard Health Alliance Inc

Doing business as Brevard Health Alliance

  • Federally Qualified Health Center (FQHC)
  • Cocoa, FL
National Provider Identifier
1104549484
Registry record updated Dec 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BREVARD HEALTH ALLIANCE INC
Doing business as
Brevard Health Alliance
Practice address
905 Pineda St
Cocoa, FL 32922-6370
Phone
(321) 241-6800
Fax
(321) 241-6888
NPI assigned
Sep 22, 2022
Last updated
Dec 19, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 19, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Angela Craig
Title
Director of Billing
Phone
(321) 698-3446

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

905 Pineda St
Cocoa, FL 32922-6370

Mailing address

PO Box 1137
Melbourne, FL 32902-1137
Phone (321) 698-3446

Other names 1

  • Brevard Health Alliance Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221217000481 FL Part A Provider - Federally Qualified Health Center (FQHC) 0446201768 Practice locations: Cocoa, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104549484. Details of each certification follow.

Federally qualified health center certification: CCN 101812

Legal name
BREVARD HEALTH ALLIANCE INC
Doing business as
BREVARD HEALTH ALLIANCE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 20, 2022
Last certification
Dec 20, 2022
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Apr 1, 2003 in FL
Enrollment address
905 Pineda St
Cocoa, FL 32922-6370

Other NPIs with the same Medicare PAC ID 17

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 17

National Provider Directory

National Provider Directory
Tax ID family
The Brevard Health Alliance Inc42 organizations share this tax ID, including this one

Other organizations with this tax ID 41

Organizations that report the same tax identification number in the National Provider Directory.

View all 41

Locations

905 Pineda St
Cocoa, FL 32922

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Robert Santiago Individual Corporate DirectorBoard Member Aug 1, 2019
Lena Marie Knapp Individual Corporate DirectorBoard Member Nov 1, 2018
Brett Esrock Individual Corporate DirectorBoard Member Aug 1, 2020
Carice Cunningham Individual Corporate DirectorBoard Member Oct 1, 2020
Colleen Browne Individual Corporate DirectorBoard Member Mar 1, 2020
Erin Shea Individual Corporate DirectorBoard Member Nov 1, 2018
Kevin Hill Individual Corporate DirectorBoard Member Dec 1, 2020
Richard a Helton Individual Corporate OfficerCeo Jun 1, 2016
Corporate DirectorCeo Jun 1, 2016
W-2 Managing EmployeeCeo Jun 1, 2016
Doreen Nimblett Individual Corporate DirectorBoard Member Dec 1, 2020
Keith Donald Individual Corporate DirectorBoard Member Oct 1, 2018
Mike Young Individual Corporate DirectorBoard Member Oct 1, 2020

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1663804800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1671408000000",
    "number": "1104549484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1137",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329021137",
            "telephone_number": "321-698-3446"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "905 PINEDA ST",
            "city": "COCOA",
            "state": "FL",
            "postal_code": "329226370",
            "telephone_number": "321-241-6800",
            "fax_number": "321-241-6888"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD HEALTH ALLIANCE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-09-22",
        "last_updated": "2022-12-19",
        "certification_date": "2022-12-19",
        "status": "A",
        "authorized_official_last_name": "CRAIG",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "DIRECTOR OF BILLING",
        "authorized_official_telephone_number": "321-698-3446"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Brevard Health Alliance",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Brevard Health Alliance",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cocoa, FL

Sources for this page

Verify at the official NPI Registry.