Healthcare Provider Details

I. General information

NPI: 1184137499
Provider Name (Legal Business Name): LEE STOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 NW 11TH ST
HERMISTON OR
97838-6600
US

IV. Provider business mailing address

702 SUNSET DR
ONTARIO OR
97914-3121
US

V. Phone/Fax

Practice location:
  • Phone: 541-567-2536
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number855209
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: