Healthcare Provider Details

I. General information

NPI: 1164932828
Provider Name (Legal Business Name): RYAN LAVANCE LEE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5564 LITTLE DEBBIE PKWY STE 108
COLLEGE DALE TN
37363-4356
US

IV. Provider business mailing address

PO BOX 2362
OOLTEWAH TN
37363-2362
US

V. Phone/Fax

Practice location:
  • Phone: 423-498-3400
  • Fax:
Mailing address:
  • Phone: 423-498-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3045
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: