Provider Demographics
NPI:1679647440
Name:LEE, YONG SUP (OMD)
Entity Type:Individual
Prefix:
First Name:YONG
Middle Name:SUP
Last Name:LEE
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4514
Mailing Address - Country:US
Mailing Address - Phone:951-925-0548
Mailing Address - Fax:951-925-3048
Practice Address - Street 1:911 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4514
Practice Address - Country:US
Practice Address - Phone:951-925-0548
Practice Address - Fax:951-925-3048
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC339171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist