Provider Demographics
NPI:1639715352
Name:JACK LI, D.C., A CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:JACK LI, D.C., A CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:T
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-207-1007
Mailing Address - Street 1:12340 SANTA MONICA BLVD STE 129
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2584
Mailing Address - Country:US
Mailing Address - Phone:310-207-1007
Mailing Address - Fax:310-633-8338
Practice Address - Street 1:12340 SANTA MONICA BLVD STE 129
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2584
Practice Address - Country:US
Practice Address - Phone:310-207-1007
Practice Address - Fax:310-633-8338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty