Healthcare Provider Details

I. General information

NPI: 1891347076
Provider Name (Legal Business Name): JAEHOON LEE OPTOMETRY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71956 MAGNESIA FALLS DR
RANCHO MIRAGE CA
92270-4901
US

IV. Provider business mailing address

71956 MAGNESIA FALLS DR
RANCHO MIRAGE CA
92270-4901
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-8806
  • Fax: 760-674-8826
Mailing address:
  • Phone: 760-674-8806
  • Fax: 760-674-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JAEHOON LEE
Title or Position: CEO
Credential: OD
Phone: 617-233-4847