Provider Demographics
NPI:1831125103
Name:DISON, LEE CHARLES (ATC/LAT)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:CHARLES
Last Name:DISON
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6464 SILVER GLEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5134
Mailing Address - Country:US
Mailing Address - Phone:904-268-1007
Mailing Address - Fax:904-858-7188
Practice Address - Street 1:6464 SILVER GLEN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5134
Practice Address - Country:US
Practice Address - Phone:904-268-1007
Practice Address - Fax:904-858-7188
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer