Provider Demographics
NPI:1548487382
Name:GHM OPTICAL SHOP
Entity type:Organization
Organization Name:GHM OPTICAL SHOP
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
Authorized Official - Phone:850-505-7788
Mailing Address - Street 1:4427 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-2066
Mailing Address - Country:US
Mailing Address - Phone:850-994-0039
Mailing Address - Fax:850-994-6100
Practice Address - Street 1:4427 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-2066
Practice Address - Country:US
Practice Address - Phone:850-994-0039
Practice Address - Fax:850-994-6100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GHM OPTICAL SHOP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-20
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL37790207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0957220002Medicare NSC