Healthcare Provider Details

I. General information

NPI: 1528290004
Provider Name (Legal Business Name): ROBERT LEE DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RUSSELL DR SUITE201
ELLIJAY GA
30540-5573
US

IV. Provider business mailing address

9 RUSSELL DR SUITE 201
ELLIJAY GA
30540-5573
US

V. Phone/Fax

Practice location:
  • Phone: 706-698-9679
  • Fax: 706-698-9678
Mailing address:
  • Phone: 706-698-9679
  • Fax: 706-698-9678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR005113
License Number StateGA

VIII. Authorized Official

Name: ROBERT W LEE
Title or Position: PRESIDENT
Credential: DC
Phone: 706-698-9679