Healthcare Provider Details

I. General information

NPI: 1164111092
Provider Name (Legal Business Name): VICTOR LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON STREET GME OFFICE WESTERLY SUITE C
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

25268 TAYLOR ST APT A
LOMA LINDA CA
92354-3027
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4085
  • Fax:
Mailing address:
  • Phone: 423-933-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA209743
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: