Healthcare Provider Details

I. General information

NPI: 1043623804
Provider Name (Legal Business Name): BRIAN WELLING IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 14010
APO AP
96543-4010
US

IV. Provider business mailing address

PO BOX 290768
YIGO GU
96929-3042
US

V. Phone/Fax

Practice location:
  • Phone: 671-366-6544
  • Fax:
Mailing address:
  • Phone: 210-535-7019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: