Provider Demographics
NPI:1356858179
Name:LEE, MAGE R (DC)
Entity Type:Individual
Prefix:DR
First Name:MAGE
Middle Name:R
Last Name:LEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 MOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5601
Mailing Address - Country:US
Mailing Address - Phone:406-543-5251
Mailing Address - Fax:
Practice Address - Street 1:1203 MOUNT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5601
Practice Address - Country:US
Practice Address - Phone:406-543-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCHI-CHI-LIC-5056111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor