Provider Demographics
NPI:1689852204
Name:BREVARD VISION CENTER INC
Entity Type:Organization
Organization Name:BREVARD VISION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:H
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-631-2811
Mailing Address - Street 1:1285 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2711
Mailing Address - Country:US
Mailing Address - Phone:321-631-2811
Mailing Address - Fax:321-631-0624
Practice Address - Street 1:1285 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2711
Practice Address - Country:US
Practice Address - Phone:321-631-2811
Practice Address - Fax:321-631-0624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1365332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0877920001Medicare NSC