Healthcare Provider Details

I. General information

NPI: 1619163391
Provider Name (Legal Business Name): TRIDENT LOW VISION SPECIALTIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9565 HIGHWAY 78 BUILDING 300
LADSON SC
29456
US

IV. Provider business mailing address

1994 PINE RIDGE CIR APT 422
NORTH CHARLESTON SC
29405-6435
US

V. Phone/Fax

Practice location:
  • Phone: 843-412-2339
  • Fax:
Mailing address:
  • Phone: 843-601-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1474
License Number StateSC

VIII. Authorized Official

Name: DR. NACONDUS GRAYSON GAMBLE
Title or Position: OPTOMETRIST
Credential: OD
Phone: 843-601-0567