Healthcare Provider Details

I. General information

NPI: 1609043652
Provider Name (Legal Business Name): MR. PHOMINIK T LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8670 KELWOOD WAY SAME
SACRAMENTO CA
95828-3858
US

IV. Provider business mailing address

8670 KELWOOD WAY SAME
SACRAMENTO CA
95828-3858
US

V. Phone/Fax

Practice location:
  • Phone: 916-230-8494
  • Fax:
Mailing address:
  • Phone: 916-230-8494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: