=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730828286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREVARD PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2022
-----------------------------------------------------
Last Update Date | 08/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 759 GLENGARRY DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-609-8388
-----------------------------------------------------
Fax | 801-797-0245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 759 GLENGARRY DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-609-8388
-----------------------------------------------------
Fax | 801-797-0245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH SIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-609-8388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------