Provider Demographics
NPI:1457843120
Name:LEE, MIKE (MS)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 N VERDUGO RD APT 2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2543
Mailing Address - Country:US
Mailing Address - Phone:818-425-9209
Mailing Address - Fax:
Practice Address - Street 1:645 S BARRANCA ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-2943
Practice Address - Country:US
Practice Address - Phone:626-974-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000293972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer