Provider Demographics
NPI:1992124754
Name:BRYAN WELLS, DC LLC
Entity type:Organization
Organization Name:BRYAN WELLS, DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-633-8814
Mailing Address - Street 1:2601 20TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6632
Mailing Address - Country:US
Mailing Address - Phone:772-299-4649
Mailing Address - Fax:772-299-4651
Practice Address - Street 1:2601 20TH ST
Practice Address - Street 2:STE A
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6632
Practice Address - Country:US
Practice Address - Phone:772-299-4649
Practice Address - Fax:772-299-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10537305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFU260ZMedicare PIN