Basic Information
| Provider Information | |||||||||
| NPI: | 1568785426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR TED BRINK & ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11406 SAN JOSE BLVD | ||||||||
| Address2: | STE 1 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322237963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042603839 | ||||||||
| FaxNumber: | 9042607879 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 JENKINS ST | ||||||||
| Address2: | STE104 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048199251 | ||||||||
| FaxNumber: | 9048199293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2010 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | BRINK | ||||||||
| AuthorizedOfficialFirstName: | TED | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9042603839 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DR TED BRINK &ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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.