Provider Demographics
NPI:1922260728
Name:LEE, BO I (LIC AC)
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:I
Last Name:LEE
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12 HARRIS AVENUE
Mailing Address - Street 2:THE NEW LIFE HEALTH CENTER INC
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2848
Mailing Address - Country:US
Mailing Address - Phone:617-524-9551
Mailing Address - Fax:617-524-0345
Practice Address - Street 1:12 HARRIS AVENUE
Practice Address - Street 2:THE NEW LIFE HEALTH CENTER INC
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2848
Practice Address - Country:US
Practice Address - Phone:617-524-9551
Practice Address - Fax:617-524-0345
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0049171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist