Provider Demographics
NPI:1831425495
Name:LEE, DAE SUP (DC)
Entity type:Individual
Prefix:DR
First Name:DAE
Middle Name:SUP
Last Name:LEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19186 WHITE DOVE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6034
Mailing Address - Country:US
Mailing Address - Phone:714-350-7716
Mailing Address - Fax:951-565-8093
Practice Address - Street 1:25285 MADISON AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8981
Practice Address - Country:US
Practice Address - Phone:951-600-8198
Practice Address - Fax:951-698-4932
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27623111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor