=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811276405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN WELLNES CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2011
-----------------------------------------------------
Last Update Date | 08/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9235 E HARRY ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67207-5073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-691-8811
-----------------------------------------------------
Fax | 316-691-8868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9235 E HARRY ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67207-5073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-691-8811
-----------------------------------------------------
Fax | 316-691-8868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. QIZHI GAO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 913-871-6308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 2003012552
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------