Provider Demographics
NPI:1699786053
Name:WELLS, TRAVIS R (DC)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:R
Last Name:WELLS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5469
Mailing Address - Country:US
Mailing Address - Phone:407-846-4325
Mailing Address - Fax:407-846-4306
Practice Address - Street 1:111 S RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5469
Practice Address - Country:US
Practice Address - Phone:407-846-4325
Practice Address - Fax:407-846-4306
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8463111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH8463OtherCHIROPRACTIC LICENCE
FL27-1874681OtherTAX ID
FL381932900Medicaid
FLCH8463OtherCHIROPRACTIC LICENCE
FL381932900Medicaid