Provider Demographics
NPI:1801409529
Name:WELLSPRING CV, LLC
Entity Type:Organization
Organization Name:WELLSPRING CV, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-714-4040
Mailing Address - Street 1:PO BOX 2868
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77402-2868
Mailing Address - Country:US
Mailing Address - Phone:713-714-4040
Mailing Address - Fax:713-588-1850
Practice Address - Street 1:5373 W ALABAMA STREET
Practice Address - Street 2:STE 204
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056
Practice Address - Country:US
Practice Address - Phone:713-714-4040
Practice Address - Fax:713-588-1850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165376801Medicaid