Healthcare Provider Details

I. General information

NPI: 1861694291
Provider Name (Legal Business Name): DR. KENNETH A LEBOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 EDWIN DR
VIRGINIA BEACH VA
23462-4522
US

IV. Provider business mailing address

345 EDWIN DR
VIRGINIA BEACH VA
23462-4522
US

V. Phone/Fax

Practice location:
  • Phone: 757-630-4502
  • Fax: 757-499-2636
Mailing address:
  • Phone: 757-497-5555
  • Fax: 757-499-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0601000666
License Number StatePA

VIII. Authorized Official

Name: JAN LEBOW
Title or Position: OFFICE MANAGER
Credential:
Phone: 757-630-4502