Provider Demographics
NPI:1558176305
Name:WELL CLINIC LLC
Entity type:Organization
Organization Name:WELL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-818-4485
Mailing Address - Street 1:579 W HAYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9726
Mailing Address - Country:US
Mailing Address - Phone:208-772-6015
Mailing Address - Fax:
Practice Address - Street 1:579 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9726
Practice Address - Country:US
Practice Address - Phone:208-772-6015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center