Provider Demographics
NPI:1215336169
Name:LEE, JEONGWOO
Entity type:Individual
Prefix:
First Name:JEONGWOO
Middle Name:
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 1:420 S MANHATTAN PL APT 10
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4186
Mailing Address - Country:US
Mailing Address - Phone:213-587-1336
Mailing Address - Fax:
Practice Address - Street 1:420 S MANHATTAN PL APT 10
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-4186
Practice Address - Country:US
Practice Address - Phone:213-587-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15557171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC15557OtherCALIFORNIA ACUPUNCTURE LICENSE