Provider Demographics
NPI:1598363509
Name:THE WELL WAGON, LLC
Entity Type:Organization
Organization Name:THE WELL WAGON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SPAHN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:812-430-2633
Mailing Address - Street 1:2124 DOGOON DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-1147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2124 DOGOON DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-1147
Practice Address - Country:US
Practice Address - Phone:812-430-2633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty