Healthcare Provider Details

I. General information

NPI: 1891253506
Provider Name (Legal Business Name): WELLVOLUTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 E MAIN ST STE B
GRASS VALLEY CA
95945-5718
US

IV. Provider business mailing address

1097 E MAIN ST STE B
GRASS VALLEY CA
95945-5718
US

V. Phone/Fax

Practice location:
  • Phone: 530-306-5511
  • Fax:
Mailing address:
  • Phone: 530-306-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HEIDI C LIEN
Title or Position: PT/OWNER
Credential: PT
Phone: 530-306-5511