Provider Demographics
NPI:1356332605
Name:LEE, JEREMY JAMES (DC, ATC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JAMES
Last Name:LEE
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454-1117
Mailing Address - Country:US
Mailing Address - Phone:585-447-2775
Mailing Address - Fax:585-286-3100
Practice Address - Street 1:131 MAIN ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-1242
Practice Address - Country:US
Practice Address - Phone:585-447-2775
Practice Address - Fax:585-286-3100
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011060111N00000X
SC3263111N00000X
VT006-0001156111N00000X
NY0601024332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA7452Medicare ID - Type Unspecified
NYV05820Medicare UPIN