1003945007 NPI number — PHYLLIS WELLS CASE MANAGER CASE CO

Table of content: PHYLLIS WELLS CASE MANAGER CASE CO (NPI 1003945007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003945007 NPI number — PHYLLIS WELLS CASE MANAGER CASE CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLS
Provider First Name:
PHYLLIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CASE MANAGER CASE CO
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1003945007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 SKYLINE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-967-5570
Provider Business Mailing Address Fax Number:
479-890-5364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 EAST 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-967-5570
Provider Business Practice Location Address Fax Number:
479-890-5364
Provider Enumeration Date:
03/05/2007

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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