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General NPI Number Information
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NPI Number | 1730232075
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Entity Type | Organization
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Legal Business Name | THERON WELLS MD INCORPORATED
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 07/11/2007
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Provider Practice Location Address
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Address Line | 730 MAGNOLIA AVE
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City | CORONA
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State | CA
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Zip | 92879-3117
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Country | US
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Telephone | 951-371-9391
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Fax | 951-346-9040
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Provider Business Mailing Address
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Address Line | PO BOX 2377
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City | CORONA
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State | CA
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Zip | 92878-2377
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Country | US
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Telephone | 951-371-9391
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Fax | 951-346-9040
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Authorized Official
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Title or Position | OWNER-MD
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Name | THERON CHARLES WELLS
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Credential | MD
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Telephone | 951-371-9391
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | G69274
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License Number State | CA
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