Healthcare Provider Details

I. General information

NPI: 1740548767
Provider Name (Legal Business Name): GATEWAY VISION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 DUNN AVE SUITE 4
JACKSONVILLE FL
32218-4799
US

IV. Provider business mailing address

447 ATLANTIC BLVD SUITE #1
ATLANTIC BEACH FL
32233-4004
US

V. Phone/Fax

Practice location:
  • Phone: 904-751-4483
  • Fax:
Mailing address:
  • Phone: 904-247-0211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD S GRIMSHAW
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 904-751-4483