Provider Demographics
NPI:1629266713
Name:J J LEE OPTICAL LLC
Entity Type:Organization
Organization Name:J J LEE OPTICAL LLC
Other - Org Name:J J LEE OPTICAL LLC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CO OWNER/BOOK KEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BUCKHALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-664-5000
Mailing Address - Street 1:2317 S RANGE AVE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-5217
Mailing Address - Country:US
Mailing Address - Phone:225-664-5000
Mailing Address - Fax:225-664-5998
Practice Address - Street 1:2317 S RANGE AVE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-5217
Practice Address - Country:US
Practice Address - Phone:225-664-5000
Practice Address - Fax:225-664-5998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2146850001332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1473031Medicaid
LA5060900001Medicare NSC