Provider Demographics
NPI:1073309589
Name:LEE, CLYDE III
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:LEE
Suffix:III
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2326
Mailing Address - Country:US
Mailing Address - Phone:203-506-9150
Mailing Address - Fax:
Practice Address - Street 1:360 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2326
Practice Address - Country:US
Practice Address - Phone:203-506-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-19
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)