=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124242631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREVARD EYE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 06/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 MALABAR RD SW SUITE 105
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-674-0200
-----------------------------------------------------
Fax | 321-674-3922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 665 S APOLLO BLVD
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-1485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-984-3200
-----------------------------------------------------
Fax | 321-984-0032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GARY R HARDEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-984-3200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------