1134691264 NPI number — GEORGETTE EUGENIA WELLS

Table of content: GEORGETTE EUGENIA WELLS (NPI 1134691264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134691264 NPI number — GEORGETTE EUGENIA WELLS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLS
Provider First Name:
GEORGETTE
Provider Middle Name:
EUGENIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILTON
Provider Other First Name:
GEORGETTE
Provider Other Middle Name:
EUGENUA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SAC-IT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134691264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 639
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIENSVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53092-0639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-247-9005
Provider Business Mailing Address Fax Number:
414-247-9004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4757 N 76TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53218-4732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-358-4145
Provider Business Practice Location Address Fax Number:
414-358-5005
Provider Enumeration Date:
12/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  18197 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18197 . This is a "LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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