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General NPI Number Information
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NPI Number | 1629489406
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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 | 05/14/2014
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Last Update Date | 05/14/2014
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Provider Practice Location Address
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Address Line | 1661 SW 37TH AVE STE. 102
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City | MIAMI
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State | FL
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Zip | 33145-1754
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Country | US
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Telephone | 305-461-2400
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Fax | 305-461-2902
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Provider Business Mailing Address
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Address Line | 1661 SW 37TH AVE STE. 102
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City | MIAMI
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State | FL
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Zip | 33145-1754
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Country | US
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Telephone | 305-461-2400
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Fax | 305-461-2902
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/OWNER
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Name | DR. GALEN GRAYSON
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Credential | M.D.
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Telephone | 877-881-0022
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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