Provider Demographics
NPI:1750037040
Name:LEE, W. KIRK (ABOC)
Entity Type:Individual
Prefix:
First Name:W.
Middle Name:KIRK
Last Name:LEE
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 FLINTSTONE RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-8706
Mailing Address - Country:US
Mailing Address - Phone:251-303-5046
Mailing Address - Fax:
Practice Address - Street 1:98 HAL CROCKER RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2089
Practice Address - Country:US
Practice Address - Phone:251-303-5046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS239902156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician