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Organization Active NPI

Brevard Health Alliance Inc

  • Federally Qualified Health Center (FQHC)
  • Melbourne, FL
National Provider Identifier
1386421097
Registry record updated Oct 11, 2023
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
Practice address
1315 Valentine St
Melbourne, FL 32901-3127
Phone
(321) 241-6800
Fax
(321) 241-6890
NPI assigned
Sep 14, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 11, 2023

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

1315 Valentine St
Melbourne, FL 32901-3127

Mailing address

PO Box 1137
Melbourne, FL 32902-1137
Phone (321) 952-9696

Other names 1

  • Brevard Health Alliance Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20151124000192 FL Part B Supplier - Clinic/Group Practice 0446201768 Receives reassigned benefits from 71 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rockledge, FL; Titusville, FL; Palm Bay, FL; Melbourne, FL; Malabar, FL; Cocoa, FL
O20231208002834 FL Part A Provider - Federally Qualified Health Center (FQHC) 0446201768 Practice locations: Melbourne, FL

Federally qualified health center certification: CCN 691948

Legal name
BREVARD HEALTH ALLIANCE INC
Doing business as
BHA VALENTINE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 1, 2023
Last certification
Nov 1, 2023
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Apr 1, 2003 in FL
Enrollment address
1315 Valentine St
Melbourne, FL 32901-3127

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

Other NPIs on the same Medicare enrollment 10

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Mark Randlov Individual Corporate DirectorBoard Member Jan 1, 2023
Brett Esrock Individual Corporate DirectorBoard Member Oct 1, 2020
Barry Forbes Individual Corporate DirectorBoard Member May 1, 2021
Colleen Browne Individual Corporate DirectorBoard Member Oct 1, 2020
Joseph Flynn Individual Corporate DirectorBoard Member Jan 1, 2023
Erin Shea Individual Corporate DirectorBoard Member Oct 1, 2020
Kevin Hill Individual Corporate DirectorBoard Member Oct 1, 2020
Richard a Helton Individual Corporate OfficerCeo Oct 1, 2018
Corporate DirectorCeo Oct 1, 2020
W-2 Managing EmployeeCeo Oct 1, 2018
Leigh Pettigrew Individual Corporate DirectorBoard Member May 1, 2020
Keith Donald Individual Corporate DirectorBoard Member Oct 1, 2018
Synthia Michelle Doaks Individual Corporate DirectorBoard Member May 1, 2022
Sonja Cummings Individual Corporate DirectorBoard Member Jan 1, 2023

NPI Registry JSON

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

{
    "created_epoch": "1694649600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696982400000",
    "number": "1386421097",
    "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": "321-952-9696",
            "fax_number": "321-952-7937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1315 VALENTINE ST",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329013127",
            "telephone_number": "321-241-6800",
            "fax_number": "321-241-6890"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD HEALTH ALLIANCE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-09-14",
        "last_updated": "2023-10-11",
        "certification_date": "2023-10-11",
        "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 Melbourne, FL

Sources for this page

Verify at the official NPI Registry.