Healthcare Provider Details

I. General information

NPI: 1144692013
Provider Name (Legal Business Name): BREVARD PROSTHETICS & ORTHOTICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 09/02/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 ARCOS AVE STE 104
ESTERO FL
33928-9460
US

IV. Provider business mailing address

8695 CONNECTICUT ST STE E
MERRILLVILLE IN
46410-6240
US

V. Phone/Fax

Practice location:
  • Phone: 239-955-4778
  • Fax: 321-638-4559
Mailing address:
  • Phone: 321-225-8001
  • Fax: 321-225-4046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateFL

VIII. Authorized Official

Name: LAURA ALLEN
Title or Position: CONTRACTING MANAGER
Credential:
Phone: 336-339-9671