Provider Demographics
NPI:1184908055
Name:LI, SHIJUN (LAC, OMD)
Entity type:Individual
Prefix:
First Name:SHIJUN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:LAC, OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 JOHNSON FERRY ROAD,
Mailing Address - Street 2:BLDG 2 STE I-40
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068
Mailing Address - Country:US
Mailing Address - Phone:678-273-2472
Mailing Address - Fax:
Practice Address - Street 1:1230 JOHNSON FERRY PL
Practice Address - Street 2:BLDG 2, STE I-40
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2048
Practice Address - Country:US
Practice Address - Phone:678-273-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000262171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist