Provider Demographics
NPI:1184701112
Name:ELAINE LEE, O.D. INC.
Entity type:Organization
Organization Name:ELAINE LEE, O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELALINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-646-7443
Mailing Address - Street 1:7375 DAY CREEK BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8024
Mailing Address - Country:US
Mailing Address - Phone:909-646-7443
Mailing Address - Fax:909-646-7480
Practice Address - Street 1:7375 DAY CREEK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-8024
Practice Address - Country:US
Practice Address - Phone:909-646-7443
Practice Address - Fax:909-646-7480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10507 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0105070Medicaid
CAOP10507Medicare ID - Type Unspecified
CASD0105070Medicaid