Provider Demographics
NPI:1710453402
Name:WELLS, JEFF (CPO)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:IN
Mailing Address - Zip Code:46721-1179
Mailing Address - Country:US
Mailing Address - Phone:866-633-3961
Mailing Address - Fax:260-999-5884
Practice Address - Street 1:4109 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6894
Practice Address - Country:US
Practice Address - Phone:866-633-3961
Practice Address - Fax:260-999-5884
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier