Provider Demographics
NPI:1811583271
Name:LEE, CHANG ROH
Entity Type:Individual
Prefix:
First Name:CHANG
Middle Name:ROH
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W 6TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1823
Mailing Address - Country:US
Mailing Address - Phone:213-935-8401
Mailing Address - Fax:213-935-8403
Practice Address - Street 1:1111 W 6TH ST STE 120
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1823
Practice Address - Country:US
Practice Address - Phone:213-935-8401
Practice Address - Fax:213-935-8403
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18945171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist