Provider Demographics
NPI:1194843912
Name:LEE, FRED DOUGLASS
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:DOUGLASS
Last Name:LEE
Suffix:
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 1:661 N HARBOR BLVD APT 137
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-1746
Mailing Address - Country:US
Mailing Address - Phone:310-403-8224
Mailing Address - Fax:
Practice Address - Street 1:6055 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 900
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-2418
Practice Address - Country:US
Practice Address - Phone:323-346-0960
Practice Address - Fax:323-346-0966
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner