Provider Demographics
NPI:1720482995
Name:LEE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:906 MICHELLE CT
Mailing Address - Street 2:#213
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3465
Mailing Address - Country:US
Mailing Address - Phone:909-964-3375
Mailing Address - Fax:909-620-9800
Practice Address - Street 1:8929 WILSHIRE BLVD
Practice Address - Street 2:#304
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1938
Practice Address - Country:US
Practice Address - Phone:310-854-0529
Practice Address - Fax:310-854-0768
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 9921225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB224263OtherMEDICARE PTAN