Provider Demographics
NPI:1518171065
Name:LEE, TIMOTHY NG (MPT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:NG
Last Name:LEE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11656 BUTTERFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3956
Mailing Address - Country:US
Mailing Address - Phone:909-799-1468
Mailing Address - Fax:
Practice Address - Street 1:401 W ADA AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4241
Practice Address - Country:US
Practice Address - Phone:626-335-9810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26935314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility