Healthcare Provider Details

I. General information

NPI: 1952817439
Provider Name (Legal Business Name): DR. MAGE R. LEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 MOUNT AVE
MISSOULA MT
59801-5601
US

IV. Provider business mailing address

1203 MOUNT AVE
MISSOULA MT
59801-5601
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-5251
  • Fax:
Mailing address:
  • Phone: 406-543-5251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MAGE R LEE
Title or Position: OWNER
Credential: DC
Phone: 406-543-5251