Provider Demographics
NPI:1225324221
Name:LEE, SEUNG JIN (DAOM)
Entity Type:Individual
Prefix:DR
First Name:SEUNG JIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 W.MANCHESTER AVE.
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-3057
Mailing Address - Country:US
Mailing Address - Phone:213-249-0112
Mailing Address - Fax:213-388-1017
Practice Address - Street 1:1704 W.MANCHESTER AVE.
Practice Address - Street 2:SUITE 208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3057
Practice Address - Country:US
Practice Address - Phone:213-249-0112
Practice Address - Fax:213-388-1017
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11777171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9725740Medicaid