Healthcare Provider Details

I. General information

NPI: 1376958371
Provider Name (Legal Business Name): ELIZABETH LEE OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1771 DUNLAWTON AVE
PORT ORANGE FL
32127-4757
US

IV. Provider business mailing address

1417 ROYAL GROVE LN
PORT ORANGE FL
32129-8620
US

V. Phone/Fax

Practice location:
  • Phone: 954-665-7358
  • Fax:
Mailing address:
  • Phone: 954-665-7358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 4924
License Number StateFL

VIII. Authorized Official

Name: ELIZABETH LEE
Title or Position: PRESIDENT
Credential: O.D.
Phone: 954-665-7358