Provider Demographics
NPI:1063070399
Name:LEE, SEUNG JAE
Entity type:Individual
Prefix:
First Name:SEUNG
Middle Name:JAE
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 1:535 N HOBART BLVD APT 9
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-1877
Mailing Address - Country:US
Mailing Address - Phone:213-321-1953
Mailing Address - Fax:
Practice Address - Street 1:3030 W OLYMPIC BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6503
Practice Address - Country:US
Practice Address - Phone:213-321-1953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-01
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5394171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC2751063OtherDRIVER LICENSE