Provider Demographics
NPI:1194025957
Name:EDMOND LEE DPM, INC.
Entity Type:Organization
Organization Name:EDMOND LEE DPM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KADIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-979-4493
Mailing Address - Street 1:500 N GARFIELD AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1242
Mailing Address - Country:US
Mailing Address - Phone:626-703-4188
Mailing Address - Fax:213-617-3144
Practice Address - Street 1:500 N GARFIELD AVE STE 305
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1242
Practice Address - Country:US
Practice Address - Phone:626-703-4188
Practice Address - Fax:213-617-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA213E00000X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty