1952366122 NPI number — LORI A LEE O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952366122 NPI number — LORI A LEE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
LORI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLEMAN-LEE
Provider Other First Name:
LORI
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1952366122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6261 SKYLINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAVERLY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14892-9458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-888-7248
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18810-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-888-7248
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG002010 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0018624500003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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