Provider Demographics
NPI:1033278353
Name:WELLY, GERALD ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:ALLEN
Last Name:WELLY
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 1:2520 COLBY AVE
Mailing Address - Street 2:#107
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2994
Mailing Address - Country:US
Mailing Address - Phone:425-252-8505
Mailing Address - Fax:425-258-2544
Practice Address - Street 1:2520 COLBY AVE
Practice Address - Street 2:#107
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2994
Practice Address - Country:US
Practice Address - Phone:425-252-8505
Practice Address - Fax:425-258-2544
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00000969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007474Medicaid
T03066Medicare UPIN