Healthcare Provider Details

I. General information

NPI: 1013391275
Provider Name (Legal Business Name): BEACHES EAR, NOSE AND THROAT, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 3RD ST S SUITE 101
JACKSONVILLE BEACH FL
32250-6096
US

IV. Provider business mailing address

PO BOX 3217
PONTE VEDRA BEACH FL
32004-3217
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-4070
  • Fax: 904-247-4131
Mailing address:
  • Phone: 904-247-4070
  • Fax: 904-247-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License NumberAY1951
License Number StateFL

VIII. Authorized Official

Name: DR. JEFFREY E BRINK
Title or Position: OWNER
Credential: M.D.
Phone: 904-247-4070