Healthcare Provider Details

I. General information

NPI: 1689536617
Provider Name (Legal Business Name): PHILIP YUKBONG LEE LAC, DAOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2025
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 PRISCILLAS VW
ELLICOTT CITY MD
21043-5140
US

IV. Provider business mailing address

3102 PRISCILLAS VW
ELLICOTT CITY MD
21043-5140
US

V. Phone/Fax

Practice location:
  • Phone: 234-365-1004
  • Fax:
Mailing address:
  • Phone: 234-365-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02729
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: