Provider Demographics
NPI:1780073130
Name:LEE, ELENA
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 B ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4107
Mailing Address - Country:US
Mailing Address - Phone:510-733-0288
Mailing Address - Fax:
Practice Address - Street 1:1025 B ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4107
Practice Address - Country:US
Practice Address - Phone:510-733-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54992183500000X
CAAC16510171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No183500000XPharmacy Service ProvidersPharmacist