Provider Demographics
NPI:1164716676
Name:BREVARD ORTHOPAEDICS SPINE & PAIN CLINIC, INC
Entity Type:Organization
Organization Name:BREVARD ORTHOPAEDICS SPINE & PAIN CLINIC, INC
Other - Org Name:THE BACK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-541-1537
Mailing Address - Street 1:2222 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5594
Mailing Address - Country:US
Mailing Address - Phone:321-723-7716
Mailing Address - Fax:321-723-0604
Practice Address - Street 1:2222 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 510
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5594
Practice Address - Country:US
Practice Address - Phone:321-723-7716
Practice Address - Fax:321-723-0604
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-01
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040225700Medicaid
FL99949OtherMEDICARE