Basic Information
| Provider Information | |||||||||
| NPI: | 1649557455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREAT WALL DYNAMIC PHYSICAL THERAPY & ACUPUNCTURE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 521231 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113521231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188882600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13939 35TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113543500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188882600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 11/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | LI | ||||||||
| AuthorizedOfficialFirstName: | QIN | ||||||||
| AuthorizedOfficialMiddleName: | EVERLYN | ||||||||
| AuthorizedOfficialTitleorPosition: | RPT | ||||||||
| AuthorizedOfficialTelephone: | 7188882600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 003017 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 003017 | 01 | NY | LICENSE | OTHER |