Provider Demographics
NPI:1184769168
Name:BREVARD PROSTHETICS & ORTHOTICS, INC
Entity type:Organization
Organization Name:BREVARD PROSTHETICS & ORTHOTICS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:219-648-2644
Mailing Address - Fax:219-228-8510
Practice Address - Street 1:966 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2128
Practice Address - Country:US
Practice Address - Phone:321-638-0262
Practice Address - Fax:321-638-4559
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 Licenses
StateLicense IDTaxonomies
335E00000X
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009958700Medicaid
FL009958700Medicaid
FL022428600Medicaid