Provider Demographics
NPI:1073568473
Name:CHAN WOO LEE MEDICAL INC.
Entity Type:Organization
Organization Name:CHAN WOO LEE MEDICAL INC.
Other - Org Name:PINEBROOK MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAN
Authorized Official - Middle Name:WOO
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-636-1412
Mailing Address - Street 1:9240 GARDEN GROVE BLVD
Mailing Address - Street 2:2
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1400
Mailing Address - Country:US
Mailing Address - Phone:714-636-1412
Mailing Address - Fax:714-530-3100
Practice Address - Street 1:9240 GARDEN GROVE BLVD
Practice Address - Street 2:2
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1400
Practice Address - Country:US
Practice Address - Phone:714-636-1412
Practice Address - Fax:714-530-3100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89666261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI24681Medicare UPIN