Provider Demographics
NPI:1386033942
Name:LEE, KISEOK
Entity Type:Individual
Prefix:
First Name:KISEOK
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 1:475 NORTHERN BLVD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4819
Mailing Address - Country:US
Mailing Address - Phone:516-829-0030
Mailing Address - Fax:516-466-7723
Practice Address - Street 1:475 NORTHERN BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4819
Practice Address - Country:US
Practice Address - Phone:516-829-0030
Practice Address - Fax:516-466-7723
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037688225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist