Provider Demographics
NPI:1720515604
Name:THE GREAT SALLY, LLC
Entity Type:Organization
Organization Name:THE GREAT SALLY, LLC
Other - Org Name:A PLUS ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:669-342-7696
Mailing Address - Street 1:25 N 14TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-6201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 N 14TH ST STE 440
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6201
Practice Address - Country:US
Practice Address - Phone:669-342-7696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service