Provider Demographics
NPI:1942712633
Name:GREAT WALL CHINESE MEDICINE, LLC.
Entity Type:Organization
Organization Name:GREAT WALL CHINESE MEDICINE, LLC.
Other - Org Name:GREAT WALL CHINESE MEDICINE AND ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:QINGSONG
Authorized Official - Middle Name:
Authorized Official - Last Name:XIAO
Authorized Official - Suffix:
Authorized Official - Credentials:OMD, PHD, LAC
Authorized Official - Phone:480-429-8881
Mailing Address - Street 1:3225 N 75TH ST STE 115
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6928
Mailing Address - Country:US
Mailing Address - Phone:480-429-8881
Mailing Address - Fax:480-429-8882
Practice Address - Street 1:3225 N 75TH ST STE 115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6928
Practice Address - Country:US
Practice Address - Phone:480-429-8881
Practice Address - Fax:480-429-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0522171100000X, 171100000X
AZMT-21514225700000X, 225700000X
AZ1080171100000X
800604133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty