Provider Demographics
NPI:1255649273
Name:LEE COUNTY OPTICAL LLC
Entity type:Organization
Organization Name:LEE COUNTY OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-439-1200
Mailing Address - Street 1:1569 HIGHWAY 19 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4399
Mailing Address - Country:US
Mailing Address - Phone:229-439-1200
Mailing Address - Fax:
Practice Address - Street 1:1569 HIGHWAY 19 SOUTH
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763
Practice Address - Country:US
Practice Address - Phone:229-439-1200
Practice Address - Fax:229-255-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty