Provider Demographics
NPI:1215283379
Name:1162 MILITARY TRAIL LLC
Entity type:Organization
Organization Name:1162 MILITARY TRAIL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-295-0001
Mailing Address - Street 1:4143 LEGENDARY DR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5393
Mailing Address - Country:US
Mailing Address - Phone:850-650-4370
Mailing Address - Fax:850-650-0193
Practice Address - Street 1:4143 LEGENDARY DR
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5393
Practice Address - Country:US
Practice Address - Phone:850-650-4370
Practice Address - Fax:850-650-0193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty