Healthcare Provider Details

I. General information

NPI: 1194473132
Provider Name (Legal Business Name): RAFAEL JAE CHUL LEE PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10061 TALBERT AVE SUITE 100
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

3230 E. IMPERIAL HWY SUITE 100
BREA CA
92821-6735
US

V. Phone/Fax

Practice location:
  • Phone: 714-632-2822
  • Fax: 714-660-2231
Mailing address:
  • Phone: 714-988-8110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number301798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: