Provider Demographics
NPI:1427492032
Name:LEE, JAE WON (LAC)
Entity type:Individual
Prefix:DR
First Name:JAE WON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E BIRCH ST
Mailing Address - Street 2:DD206
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5121
Mailing Address - Country:US
Mailing Address - Phone:714-943-9241
Mailing Address - Fax:
Practice Address - Street 1:1717 E BIRCH ST
Practice Address - Street 2:DD206
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5121
Practice Address - Country:US
Practice Address - Phone:714-943-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15281171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15281Medicaid