Healthcare Provider Details

I. General information

NPI: 1184769168
Provider Name (Legal Business Name): BREVARD PROSTHETICS & ORTHOTICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 US HIGHWAY 1
ROCKLEDGE FL
32955-2128
US

IV. Provider business mailing address

3803 E LINCOLN HWY
MERRILLVILLE IN
46410-5809
US

V. Phone/Fax

Practice location:
  • Phone: 321-638-0262
  • Fax: 321-638-4559
Mailing address:
  • Phone: 219-648-2644
  • Fax: 219-228-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. SUMESH SAXENA
Title or Position: MEMBER
Credential:
Phone: 219-648-2644