Basic Information
Provider Information | |||||||||
NPI: | 1467775312 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DR TED BRINK & ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11406 SAN JOSE BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322237963 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042603839 | ||||||||
FaxNumber: | 9042607879 | ||||||||
Practice Location | |||||||||
Address1: | 1911 WELLS RD | ||||||||
Address2: |   | ||||||||
City: | ORANGE PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 320731702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042159700 | ||||||||
FaxNumber: | 9042159701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2010 | ||||||||
LastUpdateDate: | 03/08/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRINK | ||||||||
AuthorizedOfficialFirstName: | TED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9042603839 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DR TED BRINK & ASSOCIATES | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.