Provider Demographics
NPI:1669940037
Name:LEE, EUN SU (LAC)
Entity type:Individual
Prefix:MS
First Name:EUN
Middle Name:SU
Last Name:LEE
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 1:1230 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-2118
Mailing Address - Country:US
Mailing Address - Phone:415-573-5746
Mailing Address - Fax:
Practice Address - Street 1:1230 E 33RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-2118
Practice Address - Country:US
Practice Address - Phone:415-573-5746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18164171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist