MEDICARE: JOSEPHINE Y. 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	AT000695	GA

General Provider Information

NPI Number	:	1760434617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPHINE Y. LEE ATC

Provider Business Mailing Address
First Line	:	2834 VININGS CENTRAL DR SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-6785
Country	:	US
Telephone Number	:	404-352-5865
Fax Number	:

Provider Business Practice Location Address
First Line	:	GEORGIA TECH ATHLETIC ASSOCIATION
Second Line	:	150 BOBBY DODD WAY, NW
City	:	ATLANTA
State	:	GA
Zip	:	30332-0001
Country	:	US
Telephone Number	:	404-385-2960
Fax Number	:	404-894-0695

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/08/2007

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