Provider Demographics
NPI:1467235895
Name:LIEU, JUSTIN COLIN
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:COLIN
Last Name:LIEU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 S RAMONA ST
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-2939
Mailing Address - Country:US
Mailing Address - Phone:626-862-5565
Mailing Address - Fax:
Practice Address - Street 1:1126 S RAMONA ST
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-2939
Practice Address - Country:US
Practice Address - Phone:626-862-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program