Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIRO05113 | GA |
N | 111NR0400X | Rehabilitation Chiropractor | CHIRO05113 | GA |
NPI | 1124128293 |
---|---|
Provider Name | Robert W Lee |
First Address | Ellijay, GA 30540-5573 |
Second Address | Ellijay, GA 30540-5573 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 18/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
202G700756 | MEDICARE PTAN (01) | GA |
CHIRO05113 | LICENSE (01) | GA |
U46875 | (02) | GA |