Organization
HOME AT LAST OF BREVARD,INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ALVIN PAYNE (PRESIDENT)
(321) 508-4639
Entity
Organization
Contact information
Practice address
2333 JUPITER BLVD SW, PALM BAY, FL 32908-3416
(321) 508-4639
Mailing address
2333 JUPITER BLVD SW, PALM BAY, FL 32908-3416
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
—
FL
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
674701996
MEDICAID WAIVER
FL
Enumeration date
12/13/2010
Last updated
12/13/2010
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