Provider Demographics
NPI:1184952079
Name:GREAT WALL CLINIC
Entity type:Organization
Organization Name:GREAT WALL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EPHRAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLOLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-656-9025
Mailing Address - Street 1:18230 E VALLEY HWY
Mailing Address - Street 2:168
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-1259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18230 E VALLEY HWY
Practice Address - Street 2:168
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-1259
Practice Address - Country:US
Practice Address - Phone:425-656-9025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007365261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5034616OtherDSHS PROVIDER NUMBER