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General NPI Number Information
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NPI Number | 1205340866
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Entity Type | Individual
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Provider Name | TINA MARIA LEE
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Gender | Female
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Dates
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Enumeration Date | 11/18/2017
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Last Update Date | 11/18/2017
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Provider Practice Location Address
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Address Line | 604 JAMES AVE
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City | COLONIAL HEIGHTS
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State | VA
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Zip | 23834-2812
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Country | US
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Telephone | 804-722-5889
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Fax |
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Provider Business Mailing Address
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Address Line | 604 JAMES AVE
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City | COLONIAL HEIGHTS
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State | VA
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Zip | 23834-2812
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Country | US
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Telephone | 804-722-5889
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171WH0202X
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Taxonomy Name | Home Modifications Contractor
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License Number | 47-2060180
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License Number State | VA
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