Healthcare Provider Details

I. General information

NPI: 1386807964
Provider Name (Legal Business Name): KELLEE LEANGSOK TEA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14361 BEACH BLVD STE 201
WESTMINSTER CA
92683-8140
US

IV. Provider business mailing address

14361 BEACH BLVD STE 201
WESTMINSTER CA
92683-8140
US

V. Phone/Fax

Practice location:
  • Phone: 714-684-1711
  • Fax: 714-684-1920
Mailing address:
  • Phone: 714-684-1711
  • Fax: 714-775-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002088
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number13559TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: