Healthcare Provider Details

I. General information

NPI: 1598249914
Provider Name (Legal Business Name): CHARLES LEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date: 04/12/2024
Reactivation Date: 05/03/2024

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4074
  • Fax:
Mailing address:
  • Phone: 909-558-4074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: