=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740381482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEE CHIROPRACTIC & REHAB WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 12/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1247 7TH ST. #300
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-452-9146
-----------------------------------------------------
Fax | 310-452-2566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 661455
-----------------------------------------------------
City | L.A.
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-502-8999
-----------------------------------------------------
Fax | 310-458-0088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARVIN C. LEE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 310-502-8999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC-26294
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------