Provider Demographics
NPI:1467532150
Name:LEE, RUSSELL RAYMOND (PT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:RAYMOND
Last Name:LEE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31884 CASTAIC RD
Mailing Address - Street 2:SUITE C-3
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-3946
Mailing Address - Country:US
Mailing Address - Phone:661-295-0078
Mailing Address - Fax:661-295-6783
Practice Address - Street 1:31884 CASTAIC RD
Practice Address - Street 2:SUITE C-3
Practice Address - City:CASTAIC
Practice Address - State:CA
Practice Address - Zip Code:91384-3946
Practice Address - Country:US
Practice Address - Phone:661-295-0078
Practice Address - Fax:661-295-6783
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 5791174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAID WPT5791AMedicare ID - Type Unspecified