=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992840904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREVARD PROSTHETICS & ORTHOTICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 03/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2223 S WASHINGTON AVE STE A
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32780-4703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-225-8001
-----------------------------------------------------
Fax | 321-225-4046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3803 E LINCOLN HWY
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-5809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-791-9200
-----------------------------------------------------
Fax | 219-228-8510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. SUMESH SAXENA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-648-2644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------