Provider Demographics
NPI:1689059891
Name:BREVARD WELLNESS CENTER LLC
Entity type:Organization
Organization Name:BREVARD WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BICKFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OMD, LAC
Authorized Official - Phone:321-610-8935
Mailing Address - Street 1:436 BAHIA CT NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-8700
Mailing Address - Country:US
Mailing Address - Phone:321-610-8935
Mailing Address - Fax:
Practice Address - Street 1:466 N HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6858
Practice Address - Country:US
Practice Address - Phone:321-610-8935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP855171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty