=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841318011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANGWON LEE L.AC.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 07/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 FULTON AVE STE 11
-----------------------------------------------------
City | HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-3648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-642-2908
-----------------------------------------------------
Fax | 516-479-0214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 REDWOOD DR
-----------------------------------------------------
City | PLAINVIEW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11803-5215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-642-2908
-----------------------------------------------------
Fax | 877-719-0709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 003103
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------