Healthcare Provider Details

I. General information

NPI: 1003144270
Provider Name (Legal Business Name): SURGICAL ASSOCIATES OF BREVARD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 BEVERLY DR SUITE A
ROCKLEDGE FL
32955-2851
US

IV. Provider business mailing address

150 N SYKES CREEK PKWY # 300
MERRITT ISLAND FL
32953-3488
US

V. Phone/Fax

Practice location:
  • Phone: 321-637-2150
  • Fax: 321-637-2155
Mailing address:
  • Phone: 321-449-4168
  • Fax: 321-449-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SANDI LAROCHE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 321-449-4168