Provider Demographics
NPI:1073639654
Name:LI, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N CALHOUN RD
Mailing Address - Street 2:STE 104
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5902
Mailing Address - Country:US
Mailing Address - Phone:262-784-8818
Mailing Address - Fax:262-784-8818
Practice Address - Street 1:405 N CALHOUN RD
Practice Address - Street 2:STE 104
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5902
Practice Address - Country:US
Practice Address - Phone:262-784-8818
Practice Address - Fax:262-784-8818
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI352055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist