Provider Demographics
NPI:1962631119
Name:LEE, YOUNGNAM (LAC)
Entity Type:Individual
Prefix:
First Name:YOUNGNAM
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:Y
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:400 S BURNSIDE AVE APT 4C
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5478
Mailing Address - Country:US
Mailing Address - Phone:213-820-0994
Mailing Address - Fax:
Practice Address - Street 1:1080 S LA CIENEGA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2679
Practice Address - Country:US
Practice Address - Phone:310-984-1555
Practice Address - Fax:310-358-0426
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13034171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist