Provider Demographics
NPI:1922540343
Name:WELLCARE IME, LLC
Entity Type:Organization
Organization Name:WELLCARE IME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOLSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-926-6950
Mailing Address - Street 1:2825 FORT MISSOULA RD
Mailing Address - Street 2:COMMUNITY BLDG 1, SUITE 101
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7420
Mailing Address - Country:US
Mailing Address - Phone:406-926-6950
Mailing Address - Fax:406-926-6951
Practice Address - Street 1:2825 FORT MISSOULA RD
Practice Address - Street 2:COMMUNITY BLDG 1, SUITE 101
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7420
Practice Address - Country:US
Practice Address - Phone:406-926-6950
Practice Address - Fax:406-926-6951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty