Brevard Family Walk in Clinic LLC

Primary specialty

Non-Pharmacy Dispensing SiteTaxonomy code 332900000X

License

ME86649 Issued in FL

Legal business name

BREVARD FAMILY WALK IN CLINIC LLC

Doing business as

Brevard Family Walk In Clinic Merritt Island

Practice address

1205 N Courtenay Pkwy
Merritt Island, FL 32953-5500

Phone

(321) 636-0005

NPI assigned

Jun 19, 2014

Organization subpart

Yes

Parent organization

MEDVANTX, INC.As reported in NPPES

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

Authorized official

Name

Kenny Heine

Title

VP of Operations

Phone

(858) 964-1506

Specialties & licenses 1

Addresses

Other names 1

• Brevard Family Walk In Clinic Merritt Island Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Brevard Family Walk in Clinic LLC2 organizations share this tax ID, including this one

Part of

Tri - State Medical Group Inc

Other organizations with this tax ID 1

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

• Brevard Family Walk in Clinic Rockledge

  dba Brevard Family Walk In Clinic LLC

  • Non-Pharmacy Dispensing Site
  • Rockledge, FL
  • NPI 1265846943
  NPD tax ID

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.

• Jasen S Kobobel, MD

  • Family Medicine Physician
  • Rockledge, FL
  • NPI 1073550950
  NPD (past)

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

{
    "created_epoch": "1403136000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1403136000000",
    "number": "1881008696",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5626 OBERLIN DR",
            "address_2": "SUITE 110",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921211705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1205 N COURTENAY PKWY",
            "city": "MERRITT ISLAND",
            "state": "FL",
            "postal_code": "329535500",
            "telephone_number": "321-636-0005"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD FAMILY WALK IN CLINIC LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MEDVANTX, INC.",
        "enumeration_date": "2014-06-19",
        "last_updated": "2014-06-19",
        "status": "A",
        "authorized_official_last_name": "HEINE",
        "authorized_official_first_name": "KENNY",
        "authorized_official_title_or_position": "VP OF OPERATIONS",
        "authorized_official_telephone_number": "858-964-1506"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "FL",
            "license": "ME86649",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Brevard Family Walk In Clinic Merritt Island",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Non-Pharmacy Dispensing Site in Merritt Island, FL
• Providers in Merritt Island, FL by specialty
• Non-Pharmacy Dispensing Site in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.