Provider Demographics
NPI:1629489406
Name:1162 MILITARY TRAIL LLC
Entity Type:Organization
Organization Name:1162 MILITARY TRAIL LLC
Other - Org Name:LASER EYE CENTER OF MIAMI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
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:877-881-0022
Mailing Address - Street 1:1661 SW 37TH AVE
Mailing Address - Street 2:STE. 102
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-1754
Mailing Address - Country:US
Mailing Address - Phone:305-461-2400
Mailing Address - Fax:305-461-2902
Practice Address - Street 1:1661 SW 37TH AVE
Practice Address - Street 2:STE. 102
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-1754
Practice Address - Country:US
Practice Address - Phone:305-461-2400
Practice Address - Fax:305-461-2902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty