1306889621 NPI number — LAWRENCE D LI PA-C

Table of content: LAWRENCE D LI PA-C (NPI 1306889621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306889621 NPI number — LAWRENCE D LI PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LI
Provider First Name:
LAWRENCE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306889621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 FAIR OAKS AVE STE 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-346-2455
Provider Business Mailing Address Fax Number:
626-639-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
877 E. SECOND STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91766-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-620-7769
Provider Business Practice Location Address Fax Number:
877-778-6944
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  PA15055 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: EFF:2/20/13-ELB , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EFF:2/20/13-NLB , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EFF:2/20/13-WILMINGT , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01272652/DU4032 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PA15055 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: EFF:3/11/13-ONTARIO , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01272674 . This is a "RAILROAD MEDICARE- DU4034" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PA15055 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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