Healthcare Provider Details

I. General information

NPI: 1376667972
Provider Name (Legal Business Name): DE YONG LIU LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90033-3004
US

IV. Provider business mailing address

6825 ROSEMEAD BLVD APT 2
SAN GABRIEL CA
91775-1541
US

V. Phone/Fax

Practice location:
  • Phone: 323-267-1628
  • Fax:
Mailing address:
  • Phone: 626-292-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC5911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: