Healthcare Provider Details

I. General information

NPI: 1063810745
Provider Name (Legal Business Name): KORUS MEDICAL GROUP OF LEE CHIROPRACTIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2014
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 WILSHIRE BLVD STE 100
LOS ANGELES CA
90010-1119
US

IV. Provider business mailing address

3055 WILSHIRE BLVD STE 100
LOS ANGELES CA
90010-1119
US

V. Phone/Fax

Practice location:
  • Phone: 213-383-0008
  • Fax:
Mailing address:
  • Phone: 213-383-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC29495
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC7286
License Number StateCA

VIII. Authorized Official

Name: NELSON LEE
Title or Position: D.C./DIRECTOR
Credential:
Phone: 213-383-0008