Healthcare Provider Details

I. General information

NPI: 1962748244
Provider Name (Legal Business Name): 1162 MILITARY TRAIL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

8076 W SAHARA AVE
LAS VEGAS NV
89117-7930
US

V. Phone/Fax

Practice location:
  • Phone: 305-774-0891
  • Fax: 305-774-0894
Mailing address:
  • Phone: 877-881-0022
  • Fax: 702-543-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: ERICA PERREIRA
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 877-881-0022