=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316069867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE LEE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3911 N 10TH ST SUITE G
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-687-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4121 PERIWINKLE AVE
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-5450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8513
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------