MEDICARE: DR. GARY E LEE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	278952-1202	UT

General Provider Information

NPI Number	:	1679787329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY E LEE D.C.

Provider Business Mailing Address
First Line	:	2048 WEST 5400 SOUTH
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84118
Country	:	US
Telephone Number	:	801-968-5400
Fax Number	:	801-968-5405

Provider Business Practice Location Address
First Line	:	2048 W 5400 S
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84118-1428
Country	:	US
Telephone Number	:	801-968-5400
Fax Number	:	801-968-5405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	07/08/2007

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