=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790082428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER ACUPUNCTURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2011
-----------------------------------------------------
Last Update Date | 02/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6405 NE 116TH AVE SUITE 104
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98662-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-892-4355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6405 NE 116TH AVE SUITE 104
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98662-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-892-4355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MICHAEL YOUNG JOON LEE
-----------------------------------------------------
Credential | L.AC., EAMP, MACOM
-----------------------------------------------------
Telephone | 360-892-4355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC 60197003
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------