Healthcare Provider Details

I. General information

NPI: 1285296533
Provider Name (Legal Business Name): SUNAE HYUN LEE PEDORTHIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2019
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 PLEASANT HILL RD STE 106
DULUTH GA
30096-4153
US

IV. Provider business mailing address

2550 PLEASANT HILL RD STE 106
DULUTH GA
30096-4153
US

V. Phone/Fax

Practice location:
  • Phone: 470-385-6020
  • Fax:
Mailing address:
  • Phone: 470-385-6020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberCPED4487
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPED4487
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: