Provider Demographics
NPI: | 1619333424 |
---|---|
Name: | YU JIN LEE, LAC. |
Entity Type: | Organization |
Organization Name: | YU JIN LEE, LAC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | YU JIN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LAC |
Authorized Official - Phone: | 503-961-4688 |
Mailing Address - Street 1: | 2525 SE 16TH AVE |
Mailing Address - Street 2: | UPPER |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97202-1164 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-961-4688 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 8283 SW BARBUR BLVD |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97219-2871 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-244-1330 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-01-08 |
Last Update Date: | 2016-01-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 171100000X | Other Service Providers | Acupuncturist | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | AC01282 | Other | OREGON MEDICAL BOARD |
112693 | Other | NCCAOM |