| Organization Name: | 1162 MILITARY TRAIL LLC |
| NPI Number: | 1215283379 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GALEN GRAYSON (OWNER/MEDICAL DIRECTOR) |
| Mailing Address: | 4143 Legendary Dr Destin |
| State: | FL US |
| Postal Code: | 325415393 |
| Phone Number: | 8506504370 |
| Fax Number: | 8506500193 |
| NPI Enumeration Date: | 07/26/2012 |
| NPI Last Update Date: | 07/26/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |