Provider Demographics
NPI:1124128293
Name:LEE, ROBERT W (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
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 1:9 RUSSELL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-5573
Mailing Address - Country:US
Mailing Address - Phone:706-698-9679
Mailing Address - Fax:706-698-9678
Practice Address - Street 1:9 RUSSELL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-5573
Practice Address - Country:US
Practice Address - Phone:706-698-9679
Practice Address - Fax:706-698-9678
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2018-06-18
Deactivation Date:2018-06-11
Deactivation Code:
Reactivation Date:2018-06-18
Provider Licenses
StateLicense IDTaxonomies
GACHIRO05113111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G700756OtherMEDICARE PTAN
GACHIRO05113OtherLICENSE
GAU46875Medicare UPIN
GACHIRO05113OtherLICENSE