MEDICARE: BREVARD COUNTY ORTHOPEDIC & SPINE ASSOCIATES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	OS12542	FL

General Provider Information

NPI Number	:	1588101604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREVARD COUNTY ORTHOPEDIC & SPINE ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	8929 SE BRIDGE RD
Second Line	:
City	:	HOBE SOUND
State	:	FL
Zip	:	33455-5312
Country	:	US
Telephone Number	:	772-546-9591
Fax Number	:

Provider Business Practice Location Address
First Line	:	2090 SARNO RD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-3077
Country	:	US
Telephone Number	:	321-608-8888
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JENEANE WAKULA
Credential	:
Telephone Number	:	772-546-9591

Provider Enumeration Date	:	01/26/2017
Last Update Date	:	01/26/2017

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