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General NPI Number Information
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NPI Number | 1215471107
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Entity Type | Individual
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Provider Name | LEE WENTWORTH
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Gender | Male
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Dates
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Enumeration Date | 12/12/2016
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Last Update Date | 12/12/2016
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Provider Practice Location Address
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Address Line | 23701 E EAST FORK RD
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City | AZUSA
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State | CA
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Zip | 91702-1477
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Country | US
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Telephone | 626-250-3291
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Fax |
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Provider Business Mailing Address
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Address Line | 4428 SANTA ANITA AVE APT 8
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City | EL MONTE
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State | CA
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Zip | 91731-1667
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Country | US
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Telephone | 909-378-0184
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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