1538554993 NPI number — STACEY WELLS MD

Table of content: STACEY WELLS MD (NPI 1538554993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538554993 NPI number — STACEY WELLS MD

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHEICK
Provider Other First Name:
STACEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538554993
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 CIRCLE OF HOPE DR RM 1570
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84112-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-581-8781
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 CIRCLE OF HOPE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84112-5550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-585-0303
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2015

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: 2085R0001X , with the licence number:  101042271205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101042278905 . This is a "CS MEDICAL LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 101042271205 . This is a "MEDICAL LICENCE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".