MEDICARE: BRENT RYAN WELLS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	14982	CA

General Provider Information

NPI Number	:	1043624836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT RYAN WELLS O.D.

Provider Business Mailing Address
First Line	:	2231 BAYVIEW HEIGHTS DR
Second Line	:
City	:	LOS OSOS
State	:	CA
Zip	:	93402-3900
Country	:	US
Telephone Number	:	805-528-5333
Fax Number	:

Provider Business Practice Location Address
First Line	:	2231 BAYVIEW HEIGHTS DR
Second Line	:
City	:	LOS OSOS
State	:	CA
Zip	:	93402-3900
Country	:	US
Telephone Number	:	805-528-5333
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2014
Last Update Date	:	10/16/2015

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