Provider Demographics
NPI:1518350602
Name:LEE, BRYAN JEONGROK (LAC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JEONGROK
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 1:1401 S BROOKHURST RD STE 107
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4492
Mailing Address - Country:US
Mailing Address - Phone:714-603-9088
Mailing Address - Fax:714-872-9230
Practice Address - Street 1:1401 S BROOKHURST RD STE 107
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4492
Practice Address - Country:US
Practice Address - Phone:951-201-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14610171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist