Provider Demographics
NPI:1659550051
Name:WELLS, KENNETH ALAN (LMT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALAN
Last Name:WELLS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14780 SW OSPREY DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-8028
Mailing Address - Country:US
Mailing Address - Phone:503-708-1082
Mailing Address - Fax:
Practice Address - Street 1:14780 SW OSPREY DR
Practice Address - Street 2:SUITE 350
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-8028
Practice Address - Country:US
Practice Address - Phone:503-708-1082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10956225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist