Provider Demographics
NPI:1730212218
Name:LEE HISTOLOGY LAB
Entity type:Organization
Organization Name:LEE HISTOLOGY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:HT
Authorized Official - Phone:707-528-0166
Mailing Address - Street 1:1212 FARMERS LN
Mailing Address - Street 2:4
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6747
Mailing Address - Country:US
Mailing Address - Phone:707-528-0166
Mailing Address - Fax:707-591-9351
Practice Address - Street 1:1212 FARMERS LN
Practice Address - Street 2:4
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6747
Practice Address - Country:US
Practice Address - Phone:707-528-0166
Practice Address - Fax:707-591-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX15990Medicare UPIN
CAZZZ41745ZMedicare ID - Type Unspecified