NPIMap

Organization Active NPI

Brevard Health Alliance Inc

Doing business as Family Promise Firehouse Clinic

  • Federally Qualified Health Center (FQHC)
  • Cocoa, FL
National Provider Identifier
1780450759
Registry record updated Dec 21, 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
Doing business as
Family Promise Firehouse Clinic
Practice address
114 1St St Ofc 137
Cocoa, FL 32922-7767
Phone
(321) 241-6800
Fax
(321) 241-6890
NPI assigned
Nov 30, 2023
Last updated
Dec 21, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 21, 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) 241-6834

Specialties & licenses 1

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

Addresses

Primary practice location

114 1St St Ofc 137
Cocoa, FL 32922-7767

Mailing address

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

Other names 1

  • Family Promise Firehouse Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240220001135 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 1780450759. Details of each certification follow.

Federally qualified health center certification: CCN C11012

Legal name
BREVARD HEALTH ALLIANCE INC
Doing business as
BHA FIREHOUSE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 4, 2024
Last certification
Mar 4, 2024
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Apr 1, 2003 in FL
Enrollment address
114 1St St
Ofc 137
Cocoa, FL 32922-7767

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
Brevard Health Alliance42 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

114 1st St
Ofc 137
Cocoa, FL 32922

Ownership & related parties

All disclosed owners & managing parties 13

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
Angela Craig Individual Corporate DirectorDirector of Billing Dec 1, 2023
Richard a Helton Individual Corporate OfficerCeo Oct 1, 2018
Corporate DirectorCeo Oct 1, 2018
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": "1701302400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1703116800000",
    "number": "1780450759",
    "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": "114 1ST ST OFC 137",
            "city": "COCOA",
            "state": "FL",
            "postal_code": "329227767",
            "telephone_number": "321-241-6800",
            "fax_number": "321-241-6890"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD HEALTH ALLIANCE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-11-30",
        "last_updated": "2023-12-21",
        "certification_date": "2023-12-21",
        "status": "A",
        "authorized_official_last_name": "CRAIG",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "DIRECTOR OF BILLING",
        "authorized_official_telephone_number": "321-241-6834"
    },
    "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": "Family Promise Firehouse Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Family Promise Firehouse Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cocoa, FL

Sources for this page

Verify at the official NPI Registry.