Provider Demographics
NPI:1154874147
Name:LEE, ROLAND JR
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:
Last Name:LEE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 BURNT ACORN WAY
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-3415
Mailing Address - Country:US
Mailing Address - Phone:407-963-9532
Mailing Address - Fax:
Practice Address - Street 1:5441 BURNT ACORN WAY
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-3415
Practice Address - Country:US
Practice Address - Phone:407-963-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31001154028172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver