Healthcare Provider Details

I. General information

NPI: 1073728242
Provider Name (Legal Business Name): BREVARD EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S. PATRICK DRIVE #1364
PATRICK AIR FORCE BASE FL
32925-3623
US

IV. Provider business mailing address

665 S APOLLO BLVD
MELBOURNE FL
32901-1485
US

V. Phone/Fax

Practice location:
  • Phone: 321-783-8820
  • Fax: 321-783-8962
Mailing address:
  • Phone: 321-984-3200
  • Fax: 321-984-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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