Provider Demographics
NPI:1720198310
Name:LEE, ROBERT C (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:LEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4619
Mailing Address - Country:US
Mailing Address - Phone:208-233-0067
Mailing Address - Fax:208-233-9275
Practice Address - Street 1:196 PARK AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4619
Practice Address - Country:US
Practice Address - Phone:208-233-0067
Practice Address - Fax:208-233-9275
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA8315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1673882Medicare ID - Type Unspecified