Provider Demographics
NPI:1659314151
Name:LEE, KEVIN ROBERT (DC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ROBERT
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 1:128 W WALLED LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3455
Mailing Address - Country:US
Mailing Address - Phone:248-926-1829
Mailing Address - Fax:248-926-1837
Practice Address - Street 1:128 W WALLED LAKE DR
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3455
Practice Address - Country:US
Practice Address - Phone:248-926-1829
Practice Address - Fax:248-926-1837
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKL007525111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKL007525OtherCOMMERCIAL
MI950F354240OtherBLUE CROSS/BLUE SHIELD
MIU67423Medicare UPIN
MI0M49300Medicare ID - Type Unspecified