Organization · NPI-2
1162 Military Trail LLC
Technician/Technologist, Optician · Destin, FL
NPI number1215283379
StatusActive
Last updated in NPPESJul 26, 2012
Details
- NPI
- 1215283379
- Entity type
- Organization (NPI-2)
- Legal business name
- 1162 Military Trail LLC
- Organization subpart
- No
- Enumeration date
- Jul 26, 2012
- Last updated
- Jul 26, 2012
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 156FX1800X | Technician/Technologist, Optician | – | – | Yes |
Other names
- The Eye Gallery-Destin Commons (Doing Business As)
Practice location
4143 Legendary DrDestin, FL 32541-5393
Phone 850-650-4370 · Fax 850-650-0193
Mailing address
4143 Legendary DrDestin, FL 32541-5393
Phone 850-650-4370 · Fax 850-650-0193
Authorized official
Galen Grayson
Owner/Medical Director
7042950001
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