Provider Demographics
NPI:1336783521
Name:WELLS, RICHIE JR
Entity type:Individual
Prefix:
First Name:RICHIE
Middle Name:
Last Name:WELLS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 CROTONA PKWY APT 5B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-1594
Mailing Address - Country:US
Mailing Address - Phone:347-443-3212
Mailing Address - Fax:
Practice Address - Street 1:STRATTON DRIVE
Practice Address - Street 2:PARK CENTER ATHLETIC TRAINING ROOM
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-753-4901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program