=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285859900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR SALLY LEE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 04/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5965 SEVERIN DR
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-3806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-583-4295
-----------------------------------------------------
Fax | 619-825-7300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5965 SEVERIN DR
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-3428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-583-4295
-----------------------------------------------------
Fax | 619-825-7300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. SALLY SUK YEE LEE
-----------------------------------------------------
Credential | MD,DO
-----------------------------------------------------
Telephone | 619-583-4295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 20A8088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------