Provider Demographics
NPI:1346327533
Name:FERNHOLZ, LEE A
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:A
Last Name:FERNHOLZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:W
Other - Last Name:FERNHOLZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12 E PIKES PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1504
Mailing Address - Country:US
Mailing Address - Phone:719-577-4366
Mailing Address - Fax:
Practice Address - Street 1:12 E PIKES PEAK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1504
Practice Address - Country:US
Practice Address - Phone:719-577-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO008896500000156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08100497Medicaid
CO0754590001Medicare PIN