MEDICARE: JAEHOON LEE, OD, 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	152W00000X	Optometrist	12239T	CA

General Provider Information

NPI Number	:	1558654277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAEHOON LEE, OD, INC.,

Provider Business Mailing Address
First Line	:	19179 BEAR VALLEY RD
Second Line	:	SUITE 10
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-2724
Country	:	US
Telephone Number	:	760-240-9679
Fax Number	:	760-240-8062

Provider Business Practice Location Address
First Line	:	19179 BEAR VALLEY RD
Second Line	:	SUITE 10
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-2724
Country	:	US
Telephone Number	:	760-240-9679
Fax Number	:	760-240-8062

Authorized Official
Title or Position	:	CEO
Name	:	DR. JAEHOON LEE
Credential	:	O.D.
Telephone Number	:	617-233-4847

Provider Enumeration Date	:	05/27/2011
Last Update Date	:	05/27/2011

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