Provider Demographics
NPI:1972860047
Name:LEE ADVANCED BREAST CARE LLC
Entity Type:Organization
Organization Name:LEE ADVANCED BREAST CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NARHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-536-7114
Mailing Address - Street 1:2631 WILLIAMSBURG AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1107
Mailing Address - Country:US
Mailing Address - Phone:630-536-7114
Mailing Address - Fax:
Practice Address - Street 1:2631 WILLIAMSBURG AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1107
Practice Address - Country:US
Practice Address - Phone:630-536-7114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086120208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty