Healthcare Provider Details

I. General information

NPI: 1104004035
Provider Name (Legal Business Name): GRACE HYOSUN LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1831
US

IV. Provider business mailing address

711 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1831
US

V. Phone/Fax

Practice location:
  • Phone: 323-385-5100
  • Fax: 213-807-1977
Mailing address:
  • Phone: 323-385-5100
  • Fax: 213-807-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: