Provider Demographics
NPI:1275697963
Name:LEE, KWANG BOK (DC)
Entity Type:Individual
Prefix:
First Name:KWANG
Middle Name:BOK
Last Name:LEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-0711
Mailing Address - Country:US
Mailing Address - Phone:260-356-8444
Mailing Address - Fax:260-356-8444
Practice Address - Street 1:1217 S JEFFERSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-3886
Practice Address - Country:US
Practice Address - Phone:260-356-8444
Practice Address - Fax:260-356-8444
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000684A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084613OtherANTHEM
IN371040Medicare ID - Type Unspecified