Healthcare Provider Details

I. General information

NPI: 1184806630
Provider Name (Legal Business Name): BREVARD VASCULAR ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 BEVERLY DR SUITE D
ROCKLEDGE FL
32955-2851
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 321-637-4710
  • Fax: 321-637-4715
Mailing address:
  • Phone: 321-449-4168
  • Fax: 321-449-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME91509
License Number StateFL

VIII. Authorized Official

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