Provider Demographics
NPI:1770667073
Name:RUSSELL LEE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:RUSSELL LEE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:661-295-0078
Mailing Address - Street 1:31884 CASTAIC RD
Mailing Address - Street 2:SUITE C-3
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-3946
Mailing Address - Country:US
Mailing Address - Phone:661-295-0078
Mailing Address - Fax:661-295-6783
Practice Address - Street 1:3217 MT PINOS WAY
Practice Address - Street 2:
Practice Address - City:FRAZIER PARK
Practice Address - State:CA
Practice Address - Zip Code:93225
Practice Address - Country:US
Practice Address - Phone:661-245-2003
Practice Address - Fax:661-245-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 5600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAID WPT5600AMedicare ID - Type Unspecified
CAID WPT5791AMedicare ID - Type Unspecified