Provider Demographics
NPI:1235373317
Name:LEE, KWANG JAE (LAC)
Entity Type:Individual
Prefix:MR
First Name:KWANG JAE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 PAUL AVE APT 5E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1016
Mailing Address - Country:US
Mailing Address - Phone:310-913-9286
Mailing Address - Fax:
Practice Address - Street 1:3400 PAUL AVE APT 5E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-1016
Practice Address - Country:US
Practice Address - Phone:310-913-9286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13098171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist