Provider Demographics
NPI:1851865737
Name:LI, WENLONG (LAC)
Entity Type:Individual
Prefix:
First Name:WENLONG
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
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Mailing Address - Street 1:2405 FOREST AVE., STE. 201
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128
Mailing Address - Country:US
Mailing Address - Phone:408-260-8777
Mailing Address - Fax:669-342-6085
Practice Address - Street 1:2405 FOREST AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1520
Practice Address - Country:US
Practice Address - Phone:408-260-8777
Practice Address - Fax:669-342-6085
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18347171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist