Healthcare Provider Details

I. General information

NPI: 1558287300
Provider Name (Legal Business Name): YOUNGHOON LEE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S GRAND AVE STE 703
LOS ANGELES CA
90015-3068
US

IV. Provider business mailing address

11260 KEY WEST AVE UNIT 3
PORTER RANCH CA
91326-1602
US

V. Phone/Fax

Practice location:
  • Phone: 323-408-8532
  • Fax:
Mailing address:
  • Phone: 818-263-1973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number52597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: