Provider Demographics
NPI:1740758267
Name:LEE, KWANHYEONG (ATC)
Entity Type:Individual
Prefix:MR
First Name:KWANHYEONG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 WINDHAVEN PKWY APT 3107
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-6666
Mailing Address - Country:US
Mailing Address - Phone:803-446-0651
Mailing Address - Fax:
Practice Address - Street 1:3600 WINDHAVEN PKWY APT 3107
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-6666
Practice Address - Country:US
Practice Address - Phone:803-446-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20000324312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2000032431Medicaid