Basic Information
| Provider Information | |||||||||
| NPI: | 1801290994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | J. W. LEE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2935 THOUSAND OAKS | ||||||||
| Address2: | SUITE 294 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782473312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104941100 | ||||||||
| FaxNumber: | 2104941117 | ||||||||
| Practice Location | |||||||||
| Address1: | 10500 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138655050 | ||||||||
| FaxNumber: | 8138655050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JI | ||||||||
| AuthorizedOfficialMiddleName: | WOO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5138655050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 35045945 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 2083P0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1720192990 | 01 | NPI | OTHER | 0453790 | 05 | OH | MEDICAID |