Healthcare Provider Details

I. General information

NPI: 1215283379
Provider Name (Legal Business Name): 1162 MILITARY TRAIL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 07/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4143 LEGENDARY DR
DESTIN FL
32541-5393
US

IV. Provider business mailing address

4143 LEGENDARY DR
DESTIN FL
32541-5393
US

V. Phone/Fax

Practice location:
  • Phone: 850-650-4370
  • Fax: 850-650-0193
Mailing address:
  • Phone: 850-650-4370
  • Fax: 850-650-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: DR. GALEN GRAYSON
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 704-295-0001