1558456681 NPI number — BREVARD EYE CENTER, INC

Table of content: (NPI 1558456681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558456681 NPI number — BREVARD EYE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREVARD EYE CENTER, INC
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:
1558456681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
665 S APOLLO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-1485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-984-3200
Provider Business Mailing Address Fax Number:
321-984-0032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
665 S APOLLO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-1485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-984-2346
Provider Business Practice Location Address Fax Number:
321-984-2620
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRESPALACIOS
Authorized Official First Name:
RAFAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
321-984-3200

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0539980003 . This is a "DEMERC NC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 086944900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 086944906 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 086944907 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 086944909 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1750322871 . This is a "NPI HENDRIX" identifier . This identifiers is of the category "OTHER".
  • Identifier: CK1407 . This is a "MEDICARE ID TYPE UNSPECIFIED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0539980004 . This is a "DEMERC ST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 086944904 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 086944908 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1275576712 . This is a "NPI FISHER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1942346911 . This is a "NPI REYNOLDS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 24403 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 252338807 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG1105 . This is a "MEDICARE ID TYPE UNSPECIFIED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 086944903 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1346288784 . This is a "NPI BEFANIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 252338801 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 252338802 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 252338806 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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