Provider Demographics
NPI:1700332285
Name:MINIMALLY INVASIVE THERAPIES A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE THERAPIES A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:SHIN KWON
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-349-0020
Mailing Address - Street 1:11202 LINDSAY LN
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-3637
Mailing Address - Country:US
Mailing Address - Phone:660-349-0020
Mailing Address - Fax:
Practice Address - Street 1:18400 US HIGHWAY 18
Practice Address - Street 2:SUITE A
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2306
Practice Address - Country:US
Practice Address - Phone:760-242-3939
Practice Address - Fax:760-810-7593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49819208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty