Provider Demographics
NPI:1366469140
Name:WELLCARE, LLC
Entity Type:Organization
Organization Name:WELLCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBADE
Authorized Official - Suffix:
Authorized Official - Credentials:ANP-C
Authorized Official - Phone:602-564-0078
Mailing Address - Street 1:18275 N 59TH AVE STE 138
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1253
Mailing Address - Country:US
Mailing Address - Phone:602-564-0078
Mailing Address - Fax:602-564-1154
Practice Address - Street 1:18275 N 59TH AVE STE 138
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1253
Practice Address - Country:US
Practice Address - Phone:602-564-0078
Practice Address - Fax:602-564-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ082334363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ61944Medicaid
AZP12514Medicare UPIN