Basic Information
| Provider Information | |||||||||
| NPI: | 1629489406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 1162 MILITARY TRAIL LLC | ||||||||
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| OtherOrganizationName: | LASER EYE CENTER OF MIAMI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 SW 37TH AVE | ||||||||
| Address2: | STE. 102 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331451754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054612400 | ||||||||
| FaxNumber: | 3054612902 | ||||||||
| Practice Location | |||||||||
| Address1: | 1661 SW 37TH AVE | ||||||||
| Address2: | STE. 102 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331451754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054612400 | ||||||||
| FaxNumber: | 3054612902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2014 | ||||||||
| LastUpdateDate: | 05/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | GRAYSON | ||||||||
| AuthorizedOfficialFirstName: | GALEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8778810022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.