Provider Demographics
NPI:1548960867
Name:LEE, KWANG YUP (DC, LAC)
Entity type:Individual
Prefix:DR
First Name:KWANG
Middle Name:YUP
Last Name:LEE
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 S ARDMORE AVE APT 320
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-6516
Mailing Address - Country:US
Mailing Address - Phone:213-446-5935
Mailing Address - Fax:213-770-4006
Practice Address - Street 1:440 SHATTO PL # 201A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1793
Practice Address - Country:US
Practice Address - Phone:213-446-5935
Practice Address - Fax:213-770-4006
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28510111N00000X
CAAC6428171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturist
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28510OtherCHIROPRACTOR
CAAC6428OtherACUPUNCTURIST