=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982703971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY L. WELLS LCAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 W MAIN ST STE A
-----------------------------------------------------
City | FOREST CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28043-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-248-1067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 473 KINGSWOOD DR
-----------------------------------------------------
City | FOREST CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28043-5128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 644
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------