Provider Demographics
NPI:1477566438
Name:LEE, MARVIN C (DC)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:C
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 1:1625 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE M103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3809
Mailing Address - Country:US
Mailing Address - Phone:323-375-5147
Mailing Address - Fax:323-375-5155
Practice Address - Street 1:1625 W OLYMPIC BLVD
Practice Address - Street 2:SUITE M103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3809
Practice Address - Country:US
Practice Address - Phone:323-375-5147
Practice Address - Fax:323-375-5155
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 26294111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91481Medicare UPIN
CAWDC26294AMedicare ID - Type UnspecifiedPPIN
CAW18645Medicare ID - Type UnspecifiedGROUP ID