Provider Demographics
NPI:1346723244
Name:BREVARD HEALTH GROUP LLC
Entity Type:Organization
Organization Name:BREVARD HEALTH GROUP LLC
Other - Org Name:BREVARD SPINE AND REHAB INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KATUKURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-707-0920
Mailing Address - Street 1:30 MOUNTAIN TER
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-1924
Mailing Address - Country:US
Mailing Address - Phone:828-450-7064
Mailing Address - Fax:855-422-2581
Practice Address - Street 1:1301 W EAU GALLIE BLVD STE 112
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-327-9788
Practice Address - Fax:321-320-7636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREVARD HEALTH GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-07
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)