Provider Demographics
NPI:1215320304
Name:WELLS AVE CLINIC
Entity type:Organization
Organization Name:WELLS AVE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIDUR
Authorized Official - Middle Name:SIDDHANTH
Authorized Official - Last Name:MAHADEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-247-2917
Mailing Address - Street 1:1255 S WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2504
Mailing Address - Country:US
Mailing Address - Phone:775-284-5004
Mailing Address - Fax:775-313-0894
Practice Address - Street 1:1255 S WELLS AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2504
Practice Address - Country:US
Practice Address - Phone:775-284-5004
Practice Address - Fax:775-313-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty