MEDICARE: BREVARD VISION CENTER INC

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	332H00000X	Eyewear Supplier	1365	FL

General Provider Information

NPI Number	:	1689852204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREVARD VISION CENTER INC

Provider Business Mailing Address
First Line	:	1285 S US HIGHWAY 1
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-2711
Country	:	US
Telephone Number	:	321-631-2811
Fax Number	:	321-631-0624

Provider Business Practice Location Address
First Line	:	1285 S US HIGHWAY 1
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-2711
Country	:	US
Telephone Number	:	321-631-2811
Fax Number	:	321-631-0624

Authorized Official
Title or Position	:	OWNER/OPTICIAN
Name	:	MR. MATTHEW H VERNON
Credential	:
Telephone Number	:	321-631-2811

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	05/28/2008

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