Healthcare Provider Details

I. General information

NPI: 1124049721
Provider Name (Legal Business Name): JENNY LEE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 N MILITARY TRL
RIVIERA BEACH FL
33410-7417
US

IV. Provider business mailing address

130 BELLA VISTA WAY
ROYAL PALM BEACH FL
33411-4308
US

V. Phone/Fax

Practice location:
  • Phone: 561-422-8335
  • Fax: 561-422-7682
Mailing address:
  • Phone: 561-333-7280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC3356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: