Healthcare Provider Details

I. General information

NPI: 1992840904
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

2223 S WASHINGTON AVE STE A
TITUSVILLE FL
32780-4703
US

IV. Provider business mailing address

3803 E LINCOLN HWY
MERRILLVILLE IN
46410-5809
US

V. Phone/Fax

Practice location:
  • Phone: 321-225-8001
  • Fax: 321-225-4046
Mailing address:
  • Phone: 219-791-9200
  • Fax: 219-228-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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