Provider Demographics
NPI:1942651294
Name:LI, JINGCHEN (LAC)
Entity Type:Individual
Prefix:
First Name:JINGCHEN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 E VALLEY BLVD
Mailing Address - Street 2:248A
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3668
Mailing Address - Country:US
Mailing Address - Phone:626-309-9598
Mailing Address - Fax:
Practice Address - Street 1:529 E VALLEY BLVD
Practice Address - Street 2:248A
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3668
Practice Address - Country:US
Practice Address - Phone:626-309-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15940171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC15940OtherSTATE LICENSE