Provider Demographics
NPI:1356498232
Name:WELLS VISION AND LASER EYE CENTER, LLC
Entity Type:Organization
Organization Name:WELLS VISION AND LASER EYE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-424-6677
Mailing Address - Street 1:4012 COMMONS DR W STE 110
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8424
Mailing Address - Country:US
Mailing Address - Phone:850-424-6677
Mailing Address - Fax:850-424-7271
Practice Address - Street 1:4012 COMMONS DR W STE 110
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8424
Practice Address - Country:US
Practice Address - Phone:850-424-6677
Practice Address - Fax:850-424-7271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2263152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1315210001OtherDME SUPPLIER
OK100763300AMedicaid
OK1315210001OtherDME SUPPLIER
OK900522622Medicare PIN
OK1315210001Medicare NSC