=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972848596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KO CHIN LEE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2012
-----------------------------------------------------
Last Update Date | 12/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W CHURCH ST STE 4
-----------------------------------------------------
City | UKIAH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95482-4856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-257-8115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 89
-----------------------------------------------------
City | TALMAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95481-0089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 162-625-7811
-----------------------------------------------------
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 | AC9138
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------