MEDICARE: DAVID R LEE ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1558325670	OTHER	CO	ATHLETIC TRAINING

General Provider Information

NPI Number	:	1558325670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID R LEE ATC

Provider Business Mailing Address
First Line	:	14875 NW 61ST ST
Second Line	:
City	:	PARKVILLE
State	:	MO
Zip	:	64152-3828
Country	:	US
Telephone Number	:	303-596-2126
Fax Number	:

Provider Business Practice Location Address
First Line	:	14875 NW 61ST ST
Second Line	:
City	:	PARKVILLE
State	:	MO
Zip	:	64152-3828
Country	:	US
Telephone Number	:	303-596-2126
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	01/19/2017

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