Healthcare Provider Details

I. General information

NPI: 1376959916
Provider Name (Legal Business Name): BREVARD EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E MARKS ST
ORLANDO FL
32803-3819
US

IV. Provider business mailing address

665 S APOLLO BLVD
MELBOURNE FL
32901-1485
US

V. Phone/Fax

Practice location:
  • Phone: 407-841-6220
  • Fax: 407-423-2285
Mailing address:
  • Phone: 321-984-3200
  • Fax: 321-984-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME98468
License Number StateFL

VIII. Authorized Official

Name: MR. GARY R HARDEY
Title or Position: CEO
Credential:
Phone: 321-984-2346