Provider Demographics
NPI:1427423870
Name:LEE, JONG TAI
Entity type:Individual
Prefix:
First Name:JONG
Middle Name:TAI
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 1:148 CASUDA CANYON DR
Mailing Address - Street 2:F
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-2234
Mailing Address - Country:US
Mailing Address - Phone:213-235-6563
Mailing Address - Fax:
Practice Address - Street 1:148 CASUDA CANYON DR
Practice Address - Street 2:F
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-2234
Practice Address - Country:US
Practice Address - Phone:213-235-6563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13384171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist