Provider Demographics
NPI:1609103357
Name:LEE, KYUNG YEOL (LAC)
Entity Type:Individual
Prefix:MR
First Name:KYUNG
Middle Name:YEOL
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 1:1300 25TH AVE
Mailing Address - Street 2:#100
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122
Mailing Address - Country:US
Mailing Address - Phone:415-766-5678
Mailing Address - Fax:415-373-1708
Practice Address - Street 1:1300 25TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-1563
Practice Address - Country:US
Practice Address - Phone:415-766-5678
Practice Address - Fax:415-373-1708
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11924171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11924OtherAUPUNCTURIST