1265979462 NPI number — MISS CRYSTAL JADE LEE ATC, CES

Table of content: MISS CRYSTAL JADE LEE ATC, CES (NPI 1265979462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265979462 NPI number — MISS CRYSTAL JADE LEE ATC, CES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
CRYSTAL
Provider Middle Name:
JADE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
ATC, CES
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265979462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4343 SHORT HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94605-4646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-289-9240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA CLARA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95050-4345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-551-3193
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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