Provider Demographics
NPI:1194940569
Name:BREVARD EYE CENTER
Entity type:Organization
Organization Name:BREVARD EYE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-984-3200
Mailing Address - Street 1:665 S APOLLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1485
Mailing Address - Country:US
Mailing Address - Phone:321-984-3200
Mailing Address - Fax:321-984-0032
Practice Address - Street 1:250 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3495
Practice Address - Country:US
Practice Address - Phone:321-453-5700
Practice Address - Fax:321-453-5370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREVARD EYE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1003075730OtherNPI DELATORRE
1750322871OtherNPI HENDRIX
FL086944906Medicaid
1558456689OtherNPI GROUP
FL252338802Medicaid
0539980003OtherDEMERC NC
1518908607OtherNPI EHRET
1477503696OtherNPI TRES