=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023661345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERIDIAN HEALTH FACTORY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2019
-----------------------------------------------------
Last Update Date | 07/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 N 10TH ST FL 2
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-2358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-987-7459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 GAINSBORO RD
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08003-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAC
-----------------------------------------------------
Name | QIUPING CHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-272-9142
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------