Provider Demographics
NPI:1053962936
Name:LEE, YOUNGCHAN
Entity type:Individual
Prefix:
First Name:YOUNGCHAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3591 KERNAN BLVD S APT 816
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-4674
Mailing Address - Country:US
Mailing Address - Phone:808-258-5530
Mailing Address - Fax:
Practice Address - Street 1:3591 KERNAN BLVD S APT 816
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-4674
Practice Address - Country:US
Practice Address - Phone:808-258-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18612171100000X
FLPT41344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist