Provider Demographics
NPI:1588773626
Name:LEE, MYEONG WON (LAC)
Entity type:Individual
Prefix:
First Name:MYEONG
Middle Name:WON
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 1:819 S ALVARADO ST
Mailing Address - Street 2:#201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-4018
Mailing Address - Country:US
Mailing Address - Phone:213-382-6178
Mailing Address - Fax:714-908-8585
Practice Address - Street 1:819 S ALVARADO ST
Practice Address - Street 2:#201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4018
Practice Address - Country:US
Practice Address - Phone:213-382-6178
Practice Address - Fax:714-908-8585
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4846171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0048460Medicaid