Provider Demographics
NPI:1801224290
Name:BREVARD NEURO CENTER
Entity Type:Organization
Organization Name:BREVARD NEURO CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSSE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MAZO-MAYORQUIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-733-2711
Mailing Address - Street 1:315 E NASA BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1939
Mailing Address - Country:US
Mailing Address - Phone:321-733-2711
Mailing Address - Fax:321-733-2011
Practice Address - Street 1:315 E NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1939
Practice Address - Country:US
Practice Address - Phone:321-733-2711
Practice Address - Fax:321-733-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89659174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty