Provider Demographics
NPI:1710057054
Name:BREVARD OPTOMETRY ASSOCIATES
Entity Type:Organization
Organization Name:BREVARD OPTOMETRY ASSOCIATES
Other - Org Name:BREVARD VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:E
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-725-4755
Mailing Address - Street 1:2420 S BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5356
Mailing Address - Country:US
Mailing Address - Phone:321-725-4755
Mailing Address - Fax:321-725-5088
Practice Address - Street 1:2420 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5356
Practice Address - Country:US
Practice Address - Phone:321-725-4755
Practice Address - Fax:321-725-5088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1857152W00000X
FLOPC0891152W00000X
FLOPC2189152W00000X
FLOPC2747152W00000X
FLOPC4006152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620059100Medicaid
FL621109700Medicaid
FL078627600Medicaid
FL078286600Medicaid
FL078847300Medicaid
FL078627600Medicaid
FL19860Medicare ID - Type Unspecified
FL20559Medicare ID - Type Unspecified
FL078847300Medicaid
FL19091Medicare ID - Type Unspecified
FLU7262ZMedicare ID - Type Unspecified
FL078286600Medicaid
FLV09032Medicare UPIN
FL620059100Medicaid
FL1273940002Medicare NSC
FLT77518Medicare UPIN
FL621109700Medicaid