Provider Demographics
NPI:1477884880
Name:MEDLEE FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:MEDLEE FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HOON
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-650-0309
Mailing Address - Street 1:355 PLACENTIA AVE
Mailing Address - Street 2:STE. 102
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3311
Mailing Address - Country:US
Mailing Address - Phone:949-650-0309
Mailing Address - Fax:949-650-0574
Practice Address - Street 1:355 PLACENTIA AVE
Practice Address - Street 2:STE. 102
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3311
Practice Address - Country:US
Practice Address - Phone:949-650-0309
Practice Address - Fax:949-650-0574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84664174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIO7102Medicare UPIN