Provider Demographics
NPI:1164076774
Name:LEE, HYUNGWON
Entity Type:Individual
Prefix:
First Name:HYUNGWON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S OCCIDENTAL BLVD APT 212
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1579
Mailing Address - Country:US
Mailing Address - Phone:213-725-8915
Mailing Address - Fax:
Practice Address - Street 1:400 S SEPULVEDA BLVD STE 247
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6876
Practice Address - Country:US
Practice Address - Phone:310-798-6496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18592171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist