Provider Demographics
NPI:1952853061
Name:WELL-CARE CORP
Entity Type:Organization
Organization Name:WELL-CARE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:FAGBENRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-594-9110
Mailing Address - Street 1:4215 DALE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-2243
Mailing Address - Country:US
Mailing Address - Phone:571-594-9110
Mailing Address - Fax:571-526-5509
Practice Address - Street 1:4215 DALE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2243
Practice Address - Country:US
Practice Address - Phone:571-594-9110
Practice Address - Fax:571-526-5509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty