Provider Demographics
NPI:1710362033
Name:LI, MANQUN (LAC)
Entity Type:Individual
Prefix:
First Name:MANQUN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MERRY
Other - Middle Name:
Other - Last Name:LI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:370 SAN BRUNO AVE W STE F
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066
Mailing Address - Country:US
Mailing Address - Phone:650-588-8335
Mailing Address - Fax:650-588-2544
Practice Address - Street 1:370 SAN BRUNO AVE W STE F
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3164
Practice Address - Country:US
Practice Address - Phone:650-588-8335
Practice Address - Fax:650-588-2544
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4295171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist