Provider Demographics
NPI:1770063299
Name:LEE, CHOONGBAE
Entity type:Individual
Prefix:
First Name:CHOONGBAE
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 1:12156 ADRIAN ST APT 9-310
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12156 ADRIAN ST APT 9-312
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4379
Practice Address - Country:US
Practice Address - Phone:714-603-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16765171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist