Provider Demographics
NPI:1104445048
Name:EDX OF BREVARD, LLC
Entity type:Organization
Organization Name:EDX OF BREVARD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-213-8101
Mailing Address - Street 1:2955 PINEDA PLAZA WAY STE 104
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7306
Mailing Address - Country:US
Mailing Address - Phone:321-213-8101
Mailing Address - Fax:844-228-4426
Practice Address - Street 1:2955 PINEDA PLAZA WAY STE 104
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7306
Practice Address - Country:US
Practice Address - Phone:321-213-8101
Practice Address - Fax:844-228-4426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty