Provider Demographics
NPI:1194843458
Name:LEE OPTICAL
Entity type:Organization
Organization Name:LEE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNHAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:781-324-4111
Mailing Address - Street 1:103 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-4907
Mailing Address - Country:US
Mailing Address - Phone:781-324-4111
Mailing Address - Fax:781-321-4111
Practice Address - Street 1:103 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-4907
Practice Address - Country:US
Practice Address - Phone:781-324-4111
Practice Address - Fax:781-321-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1630332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0040137OtherNHP COMMONWEALTH CARE
MA0311031Medicaid