Provider Demographics
NPI:1699378125
Name:LEE, NIKOLAI (DC)
Entity Type:Individual
Prefix:DR
First Name:NIKOLAI
Middle Name:
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 1:209 DUNLAWTON AVE STE 18
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4458
Mailing Address - Country:US
Mailing Address - Phone:386-308-9076
Mailing Address - Fax:
Practice Address - Street 1:209 DUNLAWTON AVE STE 18
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4458
Practice Address - Country:US
Practice Address - Phone:386-308-9076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor