MEDICARE: WELL-CARE CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024169586	VA

General Provider Information

NPI Number	:	1952853061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELL-CARE CORP

Provider Business Mailing Address
First Line	:	4215 DALE BLVD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2243
Country	:	US
Telephone Number	:	571-594-9110
Fax Number	:	571-526-5509

Provider Business Practice Location Address
First Line	:	4215 DALE BLVD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2243
Country	:	US
Telephone Number	:	571-594-9110
Fax Number	:	571-526-5509

Authorized Official
Title or Position	:	OWNER
Name	:	CARLOS FAGBENRO
Credential	:
Telephone Number	:	571-594-9110

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	10/25/2016

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Directions to “WELL-CARE CORP ” Practice Location

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