Provider Demographics
NPI:1922006956
Name:CAPE CANAVERAL HOSPITAL, INC.
Entity type:Organization
Organization Name:CAPE CANAVERAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PULIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-434-5651
Mailing Address - Street 1:3566 N HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5714
Mailing Address - Country:US
Mailing Address - Phone:321-434-5909
Mailing Address - Fax:321-434-1928
Practice Address - Street 1:3566 N HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5714
Practice Address - Country:US
Practice Address - Phone:321-434-5909
Practice Address - Fax:321-434-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHHA210320962251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650770100Medicaid
FL107233Medicare Oscar/Certification