=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689755589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEE CHIROPRACTIC CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 10/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1875-A SOUTH 14TH STREET
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-1800
-----------------------------------------------------
Fax | 904-261-1830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1875-A S 14TH ST
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-1800
-----------------------------------------------------
Fax | 904-261-1830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ELIZABETH ANNE HARRELSON-LEE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 904-261-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------