Basic Information
| Provider Information | |||||||||
| NPI: | 1861668964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLEMING ISLAND VISION CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEARLE VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11406-1 SAN JOSE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042603839 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1524 COUNTY ROAD 220 STE 5 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046372000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2008 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRINK | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | MELVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9042603839 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC3085 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.