Provider Demographics
NPI:1295045078
Name:LEE, JONGMOO (LAC)
Entity Type:Individual
Prefix:MR
First Name:JONGMOO
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 1:9872 CHAPMAN AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-2718
Mailing Address - Country:US
Mailing Address - Phone:714-591-5956
Mailing Address - Fax:714-676-1697
Practice Address - Street 1:9872 CHAPMAN AVE STE 114
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-2718
Practice Address - Country:US
Practice Address - Phone:714-591-5956
Practice Address - Fax:714-676-1697
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13616171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 13616OtherACUPUNCTURE BOARD