Provider Demographics
NPI:1164695763
Name:LEE, SEUNGJAE
Entity Type:Individual
Prefix:DR
First Name:SEUNGJAE
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 1:2619 GLENGYLE DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22181-5570
Mailing Address - Country:US
Mailing Address - Phone:703-471-4600
Mailing Address - Fax:703-471-4601
Practice Address - Street 1:12030 NORTH SHORE DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-471-4600
Practice Address - Fax:703-471-4601
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556582111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic