Provider Demographics
NPI:1730480070
Name:LEE, MARK M (RPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:LEE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 POTRILLO RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-5126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23133 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3729
Practice Address - Country:US
Practice Address - Phone:310-373-3181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist