NPIMap

Organization Active NPI

1162 Military Trail LLC

Doing business as The Eye Gallery-Destin Commons

  • Optician
  • Destin, FL
National Provider Identifier
1215283379
Registry record updated Jul 26, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
OpticianTaxonomy code 156FX1800X
Legal business name
1162 MILITARY TRAIL LLC
Doing business as
The Eye Gallery-Destin Commons
Practice address
4143 Legendary Dr
Destin, FL 32541-5393
Phone
(850) 650-4370
Fax
(850) 650-0193
NPI assigned
Jul 26, 2012
Last updated
Jul 26, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 26, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Galen Grayson, M.D.
Title
Owner/Medical Director
Phone
(704) 295-0001

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optician 156FX1800X Primary

Addresses

Primary practice location

4143 Legendary Dr
Destin, FL 32541-5393

Mailing address

4143 Legendary Dr
Destin, FL 32541-5393
Phone (850) 650-4370

Other names 1

  • The Eye Gallery-Destin Commons Doing business as

National Provider Directory

National Provider Directory
Tax ID family
1162 Military Trail LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4143 Legendary Dr
Destin, FL 32541
Phone (850) 650-4370

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1343260800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1343260800000",
    "number": "1215283379",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4143 LEGENDARY DR",
            "city": "DESTIN",
            "state": "FL",
            "postal_code": "325415393",
            "telephone_number": "850-650-4370",
            "fax_number": "850-650-0193"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4143 LEGENDARY DR",
            "city": "DESTIN",
            "state": "FL",
            "postal_code": "325415393",
            "telephone_number": "850-650-4370",
            "fax_number": "850-650-0193"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "1162 MILITARY TRAIL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-07-26",
        "last_updated": "2012-07-26",
        "status": "A",
        "authorized_official_last_name": "GRAYSON",
        "authorized_official_first_name": "GALEN",
        "authorized_official_title_or_position": "OWNER/MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "704-295-0001",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "156FX1800X",
            "taxonomy_group": "",
            "desc": "Technician/Technologist, Optician",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Eye Gallery-Destin Commons",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Destin, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.