Healthcare Provider Details

I. General information

NPI: 1841572427
Provider Name (Legal Business Name): 1162 MILITARY TRAIL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7326 LAKE UNDERHILL RD
ORLANDO FL
32822-6055
US

IV. Provider business mailing address

7326 LAKE UNDERHILL RD
ORLANDO FL
32822-6055
US

V. Phone/Fax

Practice location:
  • Phone: 407-380-2020
  • Fax:
Mailing address:
  • Phone: 407-380-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEPHEN MCCORMACK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 877-881-0022