Healthcare Provider Details

I. General information

NPI: 1043497332
Provider Name (Legal Business Name): IVAN LIU ACUPUNCTURIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3107 DEL MAR AVE
ROSEMEAD CA
91770-2366
US

IV. Provider business mailing address

3107 DEL MAR AVE
ROSEMEAD CA
91770-2366
US

V. Phone/Fax

Practice location:
  • Phone: 626-282-7488
  • Fax: 626-571-7488
Mailing address:
  • Phone: 626-282-7488
  • Fax: 626-571-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC11487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: