Provider Demographics
NPI:1528290004
Name:ROBERT LEE DC PC
Entity type:Organization
Organization Name:ROBERT LEE DC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-698-9679
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:SUITE201
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005113111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G700756OtherMEDICARE PTAN
GA=========OtherTAX ID NUMBER