1407182819 NPI number — ORTHOPAEDIC ASSOCIATES OF BREVARD LLC

Table of content: (NPI 1407182819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407182819 NPI number — ORTHOPAEDIC ASSOCIATES OF BREVARD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPAEDIC ASSOCIATES OF BREVARD 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:
6
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:
1407182819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2009
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:
# 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:
1344 S APOLLO BLVD
Provider Second Line Business Practice Location Address:
# 302
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-309-2884
Provider Business Practice Location Address Fax Number:
321-309-2807
Provider Enumeration Date:
10/20/2009

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: 207X00000X , with the licence number:  ME93258 , 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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