Basic Information
| Provider Information | |||||||||
| NPI: | 1396392882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JI SOO | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3319 CAMINITO EASTBLUFF UNIT 179 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920372869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4086051183 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7090 MIRATECH DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921213109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583046440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-96269 | CA | Y |
No ID Information.