Provider Demographics
NPI:1902128168
Name:LEE, RANDY JR (DN)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:LEE
Suffix:JR
Gender:M
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 CONRAD LN
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-8167
Mailing Address - Country:US
Mailing Address - Phone:815-725-3862
Mailing Address - Fax:
Practice Address - Street 1:1701 N LARKIN AVE
Practice Address - Street 2:SUITE 317
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1970
Practice Address - Country:US
Practice Address - Phone:815-744-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL181.000362172P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172P00000XOther Service ProvidersNaprapath