Provider Demographics
NPI:1427138650
Name:DR. TED BRINK AND ASSOCIATES PA
Entity type:Organization
Organization Name:DR. TED BRINK AND ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INSURANCE AND TRAINING
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-446-7009
Mailing Address - Street 1:12276 SAN JOSE BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8632
Mailing Address - Country:US
Mailing Address - Phone:904-503-3565
Mailing Address - Fax:904-647-9620
Practice Address - Street 1:11406 SAN JOSE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7953
Practice Address - Country:US
Practice Address - Phone:904-260-3839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCN700AMedicare PIN