Provider Demographics
NPI:1144692013
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:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ELDON
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:SWOPES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:321-225-8001
Mailing Address - Street 1:2223 S WASHINGTON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4703
Mailing Address - Country:US
Mailing Address - Phone:321-225-8001
Mailing Address - Fax:321-225-4046
Practice Address - Street 1:10201 ARCOS AVE STE 104
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9460
Practice Address - Country:US
Practice Address - Phone:239-955-4778
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:2015-10-30
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016079800Medicaid
FL1161540005Medicare NSC