Healthcare Provider Details

I. General information

NPI: 1679190870
Provider Name (Legal Business Name): SEAN WELLS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 07/03/2020
Certification Date: 07/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 WOODCLIFF CIR SE
GRAND RAPIDS MI
49506-3155
US

IV. Provider business mailing address

2070 INNWOOD DR SE
GRAND RAPIDS MI
49508-5066
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 847-393-5953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: