Provider Demographics
NPI:1619163391
Name:TRIDENT LOW VISION SPECIALTIES, LLC
Entity Type:Organization
Organization Name:TRIDENT LOW VISION SPECIALTIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NACONDUS
Authorized Official - Middle Name:GRAYSON
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-601-0567
Mailing Address - Street 1:1994 PINE RIDGE CIR
Mailing Address - Street 2:APT 422
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-6435
Mailing Address - Country:US
Mailing Address - Phone:843-601-0567
Mailing Address - Fax:
Practice Address - Street 1:9565 HIGHWAY 78
Practice Address - Street 2:BUILDING 300
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456
Practice Address - Country:US
Practice Address - Phone:843-412-2339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1474261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service