Provider Demographics
NPI:1770645681
Name:LEE, CHARLES C (DC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
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 1:20 E NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3223
Mailing Address - Country:US
Mailing Address - Phone:847-342-9033
Mailing Address - Fax:847-818-8111
Practice Address - Street 1:20 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3223
Practice Address - Country:US
Practice Address - Phone:847-342-9033
Practice Address - Fax:847-255-8441
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007948111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001622195OtherBLUE CROSS BLUE SHIELD
U67033Medicare UPIN
IL0001622195OtherBLUE CROSS BLUE SHIELD