MEDICARE: MR. LEE COOK L.D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FC0800X	Contact Lens Technician/Technologist	GA001342	GA
2	156FX1800X	Optician	GA001342	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GA001342	OTHER	GA	LICENSED DISPENSING OPTICIAN

General Provider Information

NPI Number	:	1790059160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEE COOK L.D.O.

Provider Business Mailing Address
First Line	:	2025 PEACHTREE RD NE
Second Line	:	SUITE 1121
City	:	ATLANTA
State	:	GA
Zip	:	30309-1413
Country	:	US
Telephone Number	:	678-463-0868
Fax Number	:

Provider Business Practice Location Address
First Line	:	2025 PEACHTREE RD NE
Second Line	:	SUITE 1121
City	:	ATLANTA
State	:	GA
Zip	:	30309-1413
Country	:	US
Telephone Number	:	678-463-0868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2012
Last Update Date	:	03/02/2012

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Directions to “ MR. LEE COOK L.D.O.” Practice Location

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