Healthcare Provider Details

I. General information

NPI: 1356756936
Provider Name (Legal Business Name): MEDWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N GILBERT RD SUITE 309
GILBERT AZ
85234-4502
US

IV. Provider business mailing address

610 N GILBERT RD SUITE 309
GILBERT AZ
85234-4502
US

V. Phone/Fax

Practice location:
  • Phone: 480-926-1111
  • Fax: 480-926-2958
Mailing address:
  • Phone: 480-926-1111
  • Fax: 480-926-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN M EBY
Title or Position: PRESIDENT
Credential:
Phone: 602-679-7676