Healthcare Provider Details

I. General information

NPI: 1942712633
Provider Name (Legal Business Name): GREAT WALL CHINESE MEDICINE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 N 75TH ST STE 115
SCOTTSDALE AZ
85251-6928
US

IV. Provider business mailing address

3225 N 75TH ST STE 115
SCOTTSDALE AZ
85251-6928
US

V. Phone/Fax

Practice location:
  • Phone: 480-429-8881
  • Fax: 480-429-8882
Mailing address:
  • Phone: 480-429-8881
  • Fax: 480-429-8882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0522
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-21514
License Number StateAZ

VIII. Authorized Official

Name: QINGSONG XIAO
Title or Position: DIRECTOR
Credential: O.M.D., PH.D., L.AC
Phone: 480-429-8881