1184806630 NPI number — BREVARD VASCULAR ASSOCIATES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184806630 NPI number — BREVARD VASCULAR ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREVARD VASCULAR ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184806630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 N SYKES CREEK PKWY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-3488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-449-4168
Provider Business Mailing Address Fax Number:
321-449-4164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1004 BEVERLY DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-2851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-637-4710
Provider Business Practice Location Address Fax Number:
321-637-4715
Provider Enumeration Date:
11/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAROCHE
Authorized Official First Name:
SANDI
Authorized Official Middle Name:
Authorized Official Title or Position:
MSO CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
321-449-4168

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  ME91509 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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