Healthcare Provider Details

I. General information

NPI: 1255872677
Provider Name (Legal Business Name): KEVIN LIU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 MARENGO ST
LOS ANGELES CA
90033-1352
US

IV. Provider business mailing address

21155 CHIRPING SPARROW RD
DIAMOND BAR CA
91765-3765
US

V. Phone/Fax

Practice location:
  • Phone: 909-263-0425
  • Fax:
Mailing address:
  • Phone: 909-263-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberE1338991
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA157221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: