Healthcare Provider Details

I. General information

NPI: 1487140869
Provider Name (Legal Business Name): JUSTIN THIEN LEE, MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 OLD RIVER RD STE 200
BAKERSFIELD CA
93311-9505
US

IV. Provider business mailing address

14182 S CANYON VINE CV
DRAPER UT
84020-5636
US

V. Phone/Fax

Practice location:
  • Phone: 661-663-6429
  • Fax: 661-663-6041
Mailing address:
  • Phone: 573-356-6998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA95245
License Number StateCA

VIII. Authorized Official

Name: JUSTIN THIEN LEE
Title or Position: PRESIDENT
Credential: MD
Phone: 573-356-6998