{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "FLEMING ISLAND VISION CENTER",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
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"OtherLastName": null,
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"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "11406-1 SAN JOSE BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "JACKSONVILLE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32223",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "904-260-3839",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1524 COUNTY ROAD 220 STE 5",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "ORANGE PARK",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32003-4913",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "904-637-2000",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/08/2008",
"LastUpdateDate": "09/06/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BRINK",
"AuthorizedOfficialFirstName": "THEODORE",
"AuthorizedOfficialMiddleName": "MELVIN",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "OD",
"AuthorizedOfficialTelephoneNumber": "904-260-3839",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "OPC3085",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}