Healthcare Provider Details

I. General information

NPI: 1548484066
Provider Name (Legal Business Name): BREVARD EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7775 N WICKHAM RD
MELBOURNE FL
32940-7914
US

IV. Provider business mailing address

665 S APOLLO BLVD
MELBOURNE FL
32901-1485
US

V. Phone/Fax

Practice location:
  • Phone: 321-984-3200
  • Fax: 321-255-1141
Mailing address:
  • Phone: 321-984-3200
  • Fax: 321-984-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY R HARDEY
Title or Position: CEO
Credential:
Phone: 321-984-3200