=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710395181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TOMOMI K LEE ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2014
-----------------------------------------------------
Last Update Date | 07/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 W 14TH ST
-----------------------------------------------------
City | CHANUTE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66720-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-431-2820
-----------------------------------------------------
Fax | 620-431-0082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 1/2 E MAIN ST APT B
-----------------------------------------------------
City | CHANUTE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66720-1837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-590-0074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 24-00687
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------