Healthcare Provider Details

I. General information

NPI: 1588701734
Provider Name (Legal Business Name): ANDREW KENNETH WELLS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/06/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 MAIN ST SUITE 203
BRAWLEY CA
92227-2392
US

IV. Provider business mailing address

622 LILAC LN
IMPERIAL CA
92251-8938
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-2800
  • Fax:
Mailing address:
  • Phone: 760-353-4271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: