Provider Demographics
NPI:1629780804
Name:WELLINGTON PROVIDER GROUP PC
Entity Type:Organization
Organization Name:WELLINGTON PROVIDER GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:MARIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-518-8817
Mailing Address - Street 1:535 WELLINGTON WAY STE 330
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1331
Mailing Address - Country:US
Mailing Address - Phone:859-518-8817
Mailing Address - Fax:859-201-1084
Practice Address - Street 1:1000 N WEST ST STE 1200
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1058
Practice Address - Country:US
Practice Address - Phone:859-518-8817
Practice Address - Fax:859-201-1084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLINGTON PROVIDER GROUP PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty