Provider Demographics
NPI:1669987152
Name:LEE, KYUNG J
Entity type:Individual
Prefix:
First Name:KYUNG
Middle Name:J
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:735 MEADOWBROOK DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9504
Practice Address - Country:US
Practice Address - Phone:989-506-5074
Practice Address - Fax:989-772-2656
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5401000204171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist