=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528250099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEE PHYSICAL THERAPY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2007
-----------------------------------------------------
Last Update Date | 08/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 E MAIN ST SUITE 1
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-585-0051
-----------------------------------------------------
Fax | 208-585-0052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 E MAIN ST. SUITE 1
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-585-0051
-----------------------------------------------------
Fax | 208-585-0052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRIAN W LEE
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 208-585-0051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PT1344
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------