Healthcare Provider Details

I. General information

NPI: 1780295550
Provider Name (Legal Business Name): GWA OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 DEVON AVE
PARK RIDGE IL
60068-4760
US

IV. Provider business mailing address

3601 SW 160TH AVE STE 400
MIRAMAR FL
33027-6312
US

V. Phone/Fax

Practice location:
  • Phone: 305-557-9004
  • Fax: 855-881-9434
Mailing address:
  • Phone: 305-557-9004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: KIM GRIFFIN
Title or Position: MANAGER
Credential:
Phone: 305-557-9004