Provider Demographics
NPI:1558654277
Name:JAEHOON LEE, OD, INC.,
Entity Type:Organization
Organization Name:JAEHOON LEE, OD, INC.,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAEHOON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:617-233-4847
Mailing Address - Street 1:19179 BEAR VALLEY RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-2724
Mailing Address - Country:US
Mailing Address - Phone:760-240-9679
Mailing Address - Fax:760-240-8062
Practice Address - Street 1:19179 BEAR VALLEY RD
Practice Address - Street 2:SUITE 10
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-2724
Practice Address - Country:US
Practice Address - Phone:760-240-9679
Practice Address - Fax:760-240-8062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12239T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty