Healthcare Provider Details

I. General information

NPI: 1629266713
Provider Name (Legal Business Name): J J LEE OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 S RANGE AVE
DENHAM SPRINGS LA
70726-5217
US

IV. Provider business mailing address

2317 S RANGE AVE
DENHAM SPRINGS LA
70726-5217
US

V. Phone/Fax

Practice location:
  • Phone: 225-664-5000
  • Fax: 225-664-5998
Mailing address:
  • Phone: 225-664-5000
  • Fax: 225-664-5998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number2146850001
License Number StateLA

VIII. Authorized Official

Name: MRS. DENISE T. BUCKHALTER
Title or Position: CO OWNER/BOOK KEEPER
Credential:
Phone: 225-664-5000