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General NPI Number Information
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NPI Number | 1619163391
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Entity Type | Organization
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Legal Business Name | TRIDENT LOW VISION SPECIALTIES, LLC
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Dates
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Enumeration Date | 09/17/2007
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Last Update Date | 09/17/2007
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Provider Practice Location Address
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Address Line | 9565 HIGHWAY 78 BUILDING 300
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City | LADSON
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State | SC
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Zip | 29456
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Country | US
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Telephone | 843-412-2339
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Fax |
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Provider Business Mailing Address
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Address Line | 1994 PINE RIDGE CIR APT 422
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City | NORTH CHARLESTON
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State | SC
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Zip | 29405-6435
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Country | US
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Telephone | 843-601-0567
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. NACONDUS GRAYSON GAMBLE
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Credential | OD
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Telephone | 843-601-0567
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 1474
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License Number State | SC
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