Provider Demographics
NPI:1104998665
Name:LEE, BRUCE B (DC)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:B
Last Name:LEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225A EAST 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-3737
Mailing Address - Country:US
Mailing Address - Phone:928-774-7165
Mailing Address - Fax:928-268-3536
Practice Address - Street 1:2225A E. 7TH AVENUE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3737
Practice Address - Country:US
Practice Address - Phone:928-774-7165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ25023Medicare ID - Type Unspecified
AZU73091Medicare UPIN