Basic Information
| Provider Information | |||||||||
| NPI: | 1720482995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 906 MICHELLE CT | ||||||||
| Address2: | #213 | ||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906403465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099643375 | ||||||||
| FaxNumber: | 9096209800 | ||||||||
| Practice Location | |||||||||
| Address1: | 8929 WILSHIRE BLVD | ||||||||
| Address2: | #304 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902111938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108540529 | ||||||||
| FaxNumber: | 3108540768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT 9921 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | CB224263 | 01 | CA | MEDICARE PTAN | OTHER |