MEDICARE: 1162 MILITARY TRAIL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	152W00000X	Optometrist
2	207W00000X	Ophthalmology Physician
3	152WC0802X	Corneal and Contact Management Optometrist

General Provider Information

NPI Number	:	1538417720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1162 MILITARY TRAIL LLC

Provider Business Mailing Address
First Line	:	8076 W SAHARA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-7930
Country	:	US
Telephone Number	:	877-881-0022
Fax Number	:	702-543-0314

Provider Business Practice Location Address
First Line	:	1616 S MILITARY TRL
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-5612
Country	:	US
Telephone Number	:	561-968-1234
Fax Number	:	561-967-9178

Authorized Official
Title or Position	:	OWNER/MEDICAL DIRECTOR
Name	:	GALEN GRAYSON
Credential	:	M.D.
Telephone Number	:	704-295-0001

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/21/2012

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