Provider Demographics
NPI:1164640025
Name:GHM OPTICAL SHOP
Entity Type:Organization
Organization Name:GHM OPTICAL SHOP
Other - Org Name:THE GLASSES STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCKNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-505-7788
Mailing Address - Street 1:6190 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6969
Mailing Address - Country:US
Mailing Address - Phone:850-505-7788
Mailing Address - Fax:850-471-0277
Practice Address - Street 1:6190 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6969
Practice Address - Country:US
Practice Address - Phone:850-505-7788
Practice Address - Fax:850-471-0277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GHM OPTICAL SHOP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2009-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL68802207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0957220001Medicare NSC