Healthcare Provider Details

I. General information

NPI: 1629489406
Provider Name (Legal Business Name): 1162 MILITARY TRAIL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 SW 37TH AVE STE. 102
MIAMI FL
33145-1754
US

IV. Provider business mailing address

1661 SW 37TH AVE STE. 102
MIAMI FL
33145-1754
US

V. Phone/Fax

Practice location:
  • Phone: 305-461-2400
  • Fax: 305-461-2902
Mailing address:
  • Phone: 305-461-2400
  • Fax: 305-461-2902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. GALEN GRAYSON
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: M.D.
Phone: 877-881-0022