Basic Information
| Provider Information | |||||||||
| NPI: | 1114245883 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YONG LUKE LEE MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10722 ARROW RTE | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917304811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842865 | ||||||||
| FaxNumber: | 9099416974 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 EAST BONITA | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917696001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094500115 | ||||||||
| FaxNumber: | 9095930096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2010 | ||||||||
| LastUpdateDate: | 11/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | YONG | ||||||||
| AuthorizedOfficialMiddleName: | LUKE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9094842865 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | A39217 | CA | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1114245883 | 05 | CA | MEDICAID |