Healthcare Provider Details

I. General information

NPI: 1700956414
Provider Name (Legal Business Name): CHARLES W. WELLY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 W BACK ST STE 101
FINCASTLE VA
24090-4368
US

IV. Provider business mailing address

PO BOX 8310
ROANOKE VA
24014-0310
US

V. Phone/Fax

Practice location:
  • Phone: 540-769-3964
  • Fax: 540-473-3458
Mailing address:
  • Phone: 540-345-3556
  • Fax: 540-342-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2248
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102204907
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: