Healthcare Provider Details

I. General information

NPI: 1720482995
Provider Name (Legal Business Name): JOHN LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8929 WILSHIRE BLVD #304
BEVERLY HILLS CA
90211-1938
US

IV. Provider business mailing address

906 MICHELLE CT #213
MONTEBELLO CA
90640-3465
US

V. Phone/Fax

Practice location:
  • Phone: 310-854-0529
  • Fax: 310-854-0768
Mailing address:
  • Phone: 909-964-3375
  • Fax: 909-620-9800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 9921
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: