Provider Demographics
NPI:1639426828
Name:LEE, BRANDON YONGJO (LAC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:YONGJO
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 1:3610 GAINESWAY TRCE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1739
Mailing Address - Country:US
Mailing Address - Phone:404-277-8999
Mailing Address - Fax:404-410-2910
Practice Address - Street 1:3610 GAINESWAY TRCE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1739
Practice Address - Country:US
Practice Address - Phone:404-277-8999
Practice Address - Fax:404-410-2910
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist