Provider Demographics
NPI:1710395181
Name:LEE, TOMOMI K (ATC)
Entity Type:Individual
Prefix:
First Name:TOMOMI
Middle Name:K
Last Name:LEE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 1/2 E MAIN ST
Mailing Address - Street 2:APT B
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-1837
Mailing Address - Country:US
Mailing Address - Phone:435-590-0074
Mailing Address - Fax:
Practice Address - Street 1:800 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-2639
Practice Address - Country:US
Practice Address - Phone:620-431-2820
Practice Address - Fax:620-431-0082
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-006872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer