Basic Information
| Provider Information | |||||||||
| NPI: | 1194843912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | DOUGLASS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 661 N HARBOR BLVD APT 137 | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907311746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104038224 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6055 E WASHINGTON BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900402418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233460960 | ||||||||
| FaxNumber: | 3233460966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.