Provider Demographics
NPI:1821193236
Name:LEE EYEWEAR INC
Entity Type:Organization
Organization Name:LEE EYEWEAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-949-5171
Mailing Address - Street 1:PO BOX 11237
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339
Mailing Address - Country:US
Mailing Address - Phone:304-949-5171
Mailing Address - Fax:
Practice Address - Street 1:2700 E DUPONT AVE STE 10
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:WV
Practice Address - Zip Code:25015-1842
Practice Address - Country:US
Practice Address - Phone:304-949-5171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0151338000Medicaid
0136770001Medicare ID - Type Unspecified