=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245609353
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSERVE, LC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2015
-----------------------------------------------------
Last Update Date | 09/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 LOCUST ST SUITE 213
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50309-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-505-2407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 LOCUST ST SUITE 213
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50309-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-505-2407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | COLLIN ALBAUGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-505-2407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------