Provider Demographics
NPI:1992840904
Name:BREVARD PROSTHETICS & ORTHOTICS, INC.
Entity Type:Organization
Organization Name:BREVARD PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:BREVARD PROSTHETICS INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SUMESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAXENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-648-2644
Mailing Address - Street 1:3803 E LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5809
Mailing Address - Country:US
Mailing Address - Phone:219-791-9200
Mailing Address - Fax:219-228-8510
Practice Address - Street 1:2223 S WASHINGTON AVE STE A
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4703
Practice Address - Country:US
Practice Address - Phone:321-225-8001
Practice Address - Fax:321-225-4046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREVARD PROSTHETICS & ORTHOTICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009959000Medicaid
FL022427800Medicaid
FL022427800Medicaid