Provider Demographics
NPI:1013056688
Name:LEE, KWANG BUM (LAC)
Entity Type:Individual
Prefix:MR
First Name:KWANG
Middle Name:BUM
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15651 IMPERIAL HWY STE 201A
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1653
Mailing Address - Country:US
Mailing Address - Phone:562-943-9800
Mailing Address - Fax:562-943-9859
Practice Address - Street 1:15651 IMPERIAL HWY STE 201A
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1653
Practice Address - Country:US
Practice Address - Phone:562-943-9800
Practice Address - Fax:562-943-9859
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8176171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist