Healthcare Provider Details

I. General information

NPI: 1083151385
Provider Name (Legal Business Name): LISHA LIU D.O.M
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 MONTGOMERY BLVD NE STE 114
ALBUQUERQUE NM
87111-2564
US

IV. Provider business mailing address

9500 MONTGOMERY BLVD NE STE 114
ALBUQUERQUE NM
87111-2564
US

V. Phone/Fax

Practice location:
  • Phone: 505-639-1349
  • Fax:
Mailing address:
  • Phone: 505-639-1349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1200
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: