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General NPI Number Information
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NPI Number | 1164920484
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Entity Type | Organization
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Legal Business Name | WELLS VISION LLC
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Dates
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Enumeration Date | 02/01/2018
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Last Update Date | 02/01/2018
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Provider Practice Location Address
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Address Line | 960 BROOKWAY BLVD
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City | BROOKHAVEN
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State | MS
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Zip | 39601-2644
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Country | US
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Telephone | 601-823-4494
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Fax |
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Provider Business Mailing Address
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Address Line | 1390 MOSES RD
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City | RAYMOND
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State | MS
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Zip | 39154-8943
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Country | US
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Telephone | 601-946-5492
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. CHANNING WELLS
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Credential | OD
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Telephone | 601-946-5492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 916
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License Number State | MS
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