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NPI Code Detail

MEDICARE: 1162 MILITARY TRAIL LLC

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 License Number License Number State
1152W00000XOptometrist

General Provider Information

NPI Number : 1841572427
Entity Type Code : Organization
Provider Name (Legal Business Name) : 1162 MILITARY TRAIL LLC
Provider Business Mailing Address
First Line : 7326 LAKE UNDERHILL RD
Second Line :
City : ORLANDO
State : FL
Zip : 32822-6055
Country : US
Telephone Number : 407-380-2020
Fax Number :
Provider Business Practice Location Address
First Line : 7326 LAKE UNDERHILL RD
Second Line :
City : ORLANDO
State : FL
Zip : 32822-6055
Country : US
Telephone Number : 407-380-2020
Fax Number :
Authorized Official
Title or Position : CHIEF EXECUTIVE OFFICER
Name : STEPHEN MCCORMACK
Credential :
Telephone Number : 877-881-0022
Provider Enumeration Date : 09/09/2011
Last Update Date : 09/09/2011

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Directions to “1162 MILITARY TRAIL LLC ” Practice Location

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