Healthcare Provider Details

I. General information

NPI: 1619616778
Provider Name (Legal Business Name): WELL-EDGE VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17134 BULVERDE RD STE 107
SAN ANTONIO TX
78247-2190
US

IV. Provider business mailing address

17134 BULVERDE RD STE 107
SAN ANTONIO TX
78247-2190
US

V. Phone/Fax

Practice location:
  • Phone: 210-267-2686
  • Fax: 210-267-2216
Mailing address:
  • Phone: 210-267-2686
  • Fax: 210-267-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: KENNEY WELLS
Title or Position: OPTOMETRIST
Credential: OD
Phone: 210-267-2686