Provider Demographics
NPI:1538307277
Name:WELL STREET
Entity Type:Organization
Organization Name:WELL STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:480-209-4844
Mailing Address - Street 1:16534 E GLENBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-2302
Mailing Address - Country:US
Mailing Address - Phone:480-209-4844
Mailing Address - Fax:480-284-5433
Practice Address - Street 1:10200 N 92ND ST
Practice Address - Street 2:SUITE # 110
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4534
Practice Address - Country:US
Practice Address - Phone:480-209-4844
Practice Address - Fax:480-284-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 2251G0304X, 2251X0800X
AZ58982251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty