Organization Name: | TRIDENT LOW VISION SPECIALTIES, LLC |
NPI Number: | 1619163391 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | NACONDUS GRAYSON GAMBLE (OPTOMETRIST) |
Mailing Address: | 9565 Highway 78 Building 300 Ladson |
State: | SC US |
Postal Code: | 29456 |
Phone Number: | 8434122339 |
Fax Number: | |
NPI Enumeration Date: | 09/17/2007 |
NPI Last Update Date: | 09/17/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QH0100X |
License Number: | 1474 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | SC |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Health Service |
Taxonomy Definition: |