Provider Demographics
NPI:1942756663
Name:LEE KIM, MOON RENG (LAC)
Entity Type:Individual
Prefix:DR
First Name:MOON RENG
Middle Name:
Last Name:LEE KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5327 HARVEST RUN DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-4877
Mailing Address - Country:US
Mailing Address - Phone:858-945-0068
Mailing Address - Fax:
Practice Address - Street 1:8303 CLAIREMONT MESA BLVD
Practice Address - Street 2:#104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1326
Practice Address - Country:US
Practice Address - Phone:858-866-6081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13397171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist