Healthcare Provider Details

I. General information

NPI: 1760391148
Provider Name (Legal Business Name): JEFFREY BENNETT WELLS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

IV. Provider business mailing address

78174 RAINBOW DR
PALM DESERT CA
92211-4300
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-1188
  • Fax: 619-659-3141
Mailing address:
  • Phone: 213-880-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95291181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: