Basic Information
| Provider Information | |||||||||
| NPI: | 1164716676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BREVARD ORTHOPAEDICS SPINE & PAIN CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE BACK CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 S HARBOR CITY BLVD | ||||||||
| Address2: | SUITE 610 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217237716 | ||||||||
| FaxNumber: | 3217230604 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 S HARBOR CITY BLVD | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217237716 | ||||||||
| FaxNumber: | 3217230604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOPEZ | ||||||||
| AuthorizedOfficialFirstName: | KATRINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3215411537 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2471M1202X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Magnetic Resonance Imaging | 247100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |
ID Information
| ID | Type | State | Issuer | Description | 040225700 | 05 | FL | MEDICAID | 99949 | 01 | FL | MEDICARE | OTHER |