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General NPI Number Information
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NPI Number | 1346735982
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Entity Type | Organization
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Legal Business Name | XYZ MEDICAL
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Dates
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Enumeration Date | 06/26/2018
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Last Update Date | 06/26/2018
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Provider Practice Location Address
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Address Line | 9 RUSSELL DR STE 201
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City | ELLIJAY
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State | GA
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Zip | 30540-5573
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Country | US
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Telephone | 706-698-9679
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Fax | 706-698-9678
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Provider Business Mailing Address
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Address Line | 9 RUSSELL DR STE 201
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City | ELLIJAY
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State | GA
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Zip | 30540-5573
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Country | US
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Telephone | 706-698-9679
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Fax | 706-698-9678
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROBERT W LEE
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Credential | DC
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Telephone | 706-698-9679
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 26097
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License Number State | GA
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