Healthcare Provider Details

I. General information

NPI: 1083540496
Provider Name (Legal Business Name): KOREY LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 CANADA AVE STE 1
BISMARCK ND
58503-1813
US

IV. Provider business mailing address

1040 CANADA AVE STE 1
BISMARCK ND
58503-1813
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-3064
  • Fax: 701-751-2265
Mailing address:
  • Phone: 701-751-3064
  • Fax: 701-751-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2929
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: