Provider Demographics
NPI:1578741302
Name:SIMON K LEE DC CHIROPRACTIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SIMON K LEE DC CHIROPRACTIC PROFESSIONAL CORPORATION
Other - Org Name:WELLNESS CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:KYEJOO
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-245-6898
Mailing Address - Street 1:730 E EL CAMINO REAL
Mailing Address - Street 2:SUITE B
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-2970
Mailing Address - Country:US
Mailing Address - Phone:408-245-6898
Mailing Address - Fax:408-245-6998
Practice Address - Street 1:730 E EL CAMINO REAL
Practice Address - Street 2:SUITE B
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2970
Practice Address - Country:US
Practice Address - Phone:408-245-6898
Practice Address - Fax:408-245-6998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 28393111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9918836Medicaid
CAV07678Medicare UPIN
CAZZZ03353ZMedicare PIN