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General NPI Number Information
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NPI Number | 1215283379
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Entity Type | Organization
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Legal Business Name | 1162 MILITARY TRAIL LLC
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Dates
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Enumeration Date | 07/26/2012
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Last Update Date | 07/26/2012
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Provider Practice Location Address
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Address Line | 4143 LEGENDARY DR
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City | DESTIN
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State | FL
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Zip | 32541-5393
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Country | US
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Telephone | 850-650-4370
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Fax | 850-650-0193
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Provider Business Mailing Address
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Address Line | 4143 LEGENDARY DR
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City | DESTIN
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State | FL
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Zip | 32541-5393
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Country | US
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Telephone | 850-650-4370
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Fax | 850-650-0193
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Authorized Official
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Title or Position | OWNER/MEDICAL DIRECTOR
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Name | DR. GALEN GRAYSON
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Credential | M.D.
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Telephone | 704-295-0001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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