Healthcare Provider Details

I. General information

NPI: 1124394663
Provider Name (Legal Business Name): EDEN VICTORIA WELLS M.D., MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S GRAND AVE 4TH FLOOR MDHHS
LANSING MI
48933-2108
US

IV. Provider business mailing address

333 S GRAND AVE 4TH FLOOR MDHHS
LANSING MI
48933-2108
US

V. Phone/Fax

Practice location:
  • Phone: 517-284-4020
  • Fax:
Mailing address:
  • Phone: 517-284-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number4301080277
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: