Provider Demographics
NPI:1356914659
Name:LEE, MCKENZIE EDWARD
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:EDWARD
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 BROADWAY UNIT E
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-2767
Mailing Address - Country:US
Mailing Address - Phone:970-644-5255
Mailing Address - Fax:
Practice Address - Street 1:2500 BROADWAY UNIT B
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81507-2767
Practice Address - Country:US
Practice Address - Phone:970-644-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0021400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO460839616OtherTAX ID