=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497078380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR TED BRINK & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2010
-----------------------------------------------------
Last Update Date | 03/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10300 SOUTHSIDE BLVD 238
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-363-8282
-----------------------------------------------------
Fax | 904-363-2263
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10300 SOUTHSIDE BLVD 238
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-363-8282
-----------------------------------------------------
Fax | 904-363-2263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TED BRINK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 904-260-3839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ME 84394
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------