MEDICARE: SUN AND MOON CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	C804338	CO

General Provider Information

NPI Number	:	1306877311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUN AND MOON CLINIC INC

Provider Business Mailing Address
First Line	:	11175 E MISSISSIPPI AVE STE 232
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80012-3137
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11175 E MISSISSIPPI AVE STE 232
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80012-3137
Country	:	US
Telephone Number	:	303-340-8977
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GWAN HO LEE
Credential	:
Telephone Number	:	303-340-8977

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	08/22/2020

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Directions to “SUN AND MOON CLINIC INC ” Practice Location

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