1558563767 NPI number — JUNG H. LEE, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558563767 NPI number — JUNG H. LEE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUNG H. LEE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558563767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRYSTAL CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63019-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-937-0817
Provider Business Mailing Address Fax Number:
636-937-8818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 INDUSTRIAL DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028-4106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-937-0817
Provider Business Practice Location Address Fax Number:
636-937-8818
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
JUNG
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
636-937-0817

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  R8562 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200016202 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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