Provider Demographics
NPI:1558736421
Name:LEE, SOOJEONG (LAC)
Entity Type:Individual
Prefix:
First Name:SOOJEONG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 EDINBURGH AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940
Mailing Address - Country:US
Mailing Address - Phone:831-706-6627
Mailing Address - Fax:
Practice Address - Street 1:505 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950
Practice Address - Country:US
Practice Address - Phone:831-645-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16742171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist