1366030173 NPI number — WELLSPECT INC

Table of content: (NPI 1366030173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366030173 NPI number — WELLSPECT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSPECT INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1366030173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1235 FRIENDSHIP RD STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRASELTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30517-5626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-356-3742
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 W ROMANA ST STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32502-5848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-456-3742
Provider Business Practice Location Address Fax Number:
866-666-6250
Provider Enumeration Date:
01/07/2021

Additional Information

Authorized Official

Authorized Official Last Name:
DOBREZ
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
815-341-9291

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115506600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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