Healthcare Provider Details

I. General information

NPI: 1356498232
Provider Name (Legal Business Name): WELLS VISION AND LASER EYE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4012 COMMONS DR W STE 110
DESTIN FL
32541-8424
US

IV. Provider business mailing address

4012 COMMONS DR W STE 110
DESTIN FL
32541-8424
US

V. Phone/Fax

Practice location:
  • Phone: 850-424-6677
  • Fax: 850-424-7271
Mailing address:
  • Phone: 850-424-6677
  • Fax: 850-424-7271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2263
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2263
License Number StateOK

VIII. Authorized Official

Name: DR. KEVIN W WELLS
Title or Position: PRESIDENT/OWNER
Credential: OD
Phone: 850-424-6677