Healthcare Provider Details

I. General information

NPI: 1164716676
Provider Name (Legal Business Name): BREVARD ORTHOPAEDICS SPINE & PAIN CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S HARBOR CITY BLVD SUITE 510
MELBOURNE FL
32901-5594
US

IV. Provider business mailing address

2222 S HARBOR CITY BLVD SUITE 610
MELBOURNE FL
32901-5594
US

V. Phone/Fax

Practice location:
  • Phone: 321-723-7716
  • Fax: 321-723-0604
Mailing address:
  • Phone: 321-723-7716
  • Fax: 321-723-0604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: KATRINA LOPEZ
Title or Position: CREDENTIALING
Credential:
Phone: 321-541-1537