Provider Demographics
NPI:1003965633
Name:DONNA L. LEE OD ,D/B/A TALLADEGA FAMILY OPTICAL
Entity Type:Organization
Organization Name:DONNA L. LEE OD ,D/B/A TALLADEGA FAMILY OPTICAL
Other - Org Name:DONNA L. LEE OD ,TALLADEGA FAMILY OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:DENSON
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-878-9027
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35161-0457
Mailing Address - Country:US
Mailing Address - Phone:256-362-9595
Mailing Address - Fax:256-362-0207
Practice Address - Street 1:112 COURT SQ S
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2461
Practice Address - Country:US
Practice Address - Phone:256-362-9595
Practice Address - Fax:256-362-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALST410TA319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-33852OtherBLUE CROSS BLUE SHIELD
AL009936628Medicaid