Provider Demographics
NPI:1104952928
Name:SOUTHEAST EYE ASSOCIATES, PLLC
Entity type:Organization
Organization Name:SOUTHEAST EYE ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:606-248-2549
Mailing Address - Street 1:1403 CUMBERLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1158
Mailing Address - Country:US
Mailing Address - Phone:606-248-2549
Mailing Address - Fax:606-248-9188
Practice Address - Street 1:1403 CUMBERLAND AVE
Practice Address - Street 2:SUITE A, BOX 979
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1158
Practice Address - Country:US
Practice Address - Phone:606-248-2549
Practice Address - Fax:606-248-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1082 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7265OtherMEDICARE PTAN
4643170001Medicare NSC