=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871834929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUB LEE L.AC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2013
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1440 S ANAHEIM BLVD # G13
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92805-6213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-684-1017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13927 FAIRWAY DR
-----------------------------------------------------
City | WHITTIER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90604-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-335-7089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC15009
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------