Provider Demographics
NPI:1396165007
Name:WELLS, GARDE
Entity type:Individual
Prefix:
First Name:GARDE
Middle Name:
Last Name:WELLS
Suffix:
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 1:581 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3816
Mailing Address - Country:US
Mailing Address - Phone:541-556-9893
Mailing Address - Fax:
Practice Address - Street 1:581 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3816
Practice Address - Country:US
Practice Address - Phone:541-556-9893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4435225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist