Provider Demographics
NPI:1588701734
Name:WELLS, ANDREW KENNETH
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:KENNETH
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 1:622 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-8938
Mailing Address - Country:US
Mailing Address - Phone:760-353-4271
Mailing Address - Fax:
Practice Address - Street 1:220 MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2392
Practice Address - Country:US
Practice Address - Phone:760-351-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator