MEDICARE: TRACY WELLS, OD PC

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	1420	CO

General Provider Information

NPI Number	:	1598209777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRACY WELLS, OD PC

Provider Business Mailing Address
First Line	:	4092 AUSTIN BLUFFS PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-5905
Country	:	US
Telephone Number	:	719-590-1765
Fax Number	:	719-590-9603

Provider Business Practice Location Address
First Line	:	4092 AUSTIN BLUFFS PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-5905
Country	:	US
Telephone Number	:	719-590-1765
Fax Number	:	719-590-9603

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. TRACY WELLS
Credential	:	OD
Telephone Number	:	719-590-1765

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	12/07/2016

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