=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376866228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. TED BRINKS & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2010
-----------------------------------------------------
Last Update Date | 03/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4495 ROOSEVELT BLVD 101
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32210-3375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-384-3707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11406 SAN JOSE BLVD STE 1
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-7963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-260-3839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TED BRINK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 904-260-3839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------