Provider Demographics
NPI:1962524751
Name:LEE, TAE JUNG (LAC)
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:JUNG
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 1:16960 BASTANCHURY RD STE J
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-1711
Mailing Address - Country:US
Mailing Address - Phone:714-943-8511
Mailing Address - Fax:714-993-3467
Practice Address - Street 1:16960 BASTANCHURY RD STE J
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-1711
Practice Address - Country:US
Practice Address - Phone:714-943-8511
Practice Address - Fax:714-993-3467
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8107171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist