Healthcare Provider Details

I. General information

NPI: 1538417720
Provider Name (Legal Business Name): 1162 MILITARY TRAIL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 S MILITARY TRL
WEST PALM BEACH FL
33415-5612
US

IV. Provider business mailing address

8076 W SAHARA AVE
LAS VEGAS NV
89117-7930
US

V. Phone/Fax

Practice location:
  • Phone: 561-968-1234
  • Fax: 561-967-9178
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 State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VIII. Authorized Official

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