Provider Demographics
NPI:1972543411
Name:WELLS, BRENT LANE (PT,DPT, OCS)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:LANE
Last Name:WELLS
Suffix:
Gender:M
Credentials:PT,DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1468
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-1468
Mailing Address - Country:US
Mailing Address - Phone:830-816-2611
Mailing Address - Fax:830-816-2688
Practice Address - Street 1:34910 IH 10 W
Practice Address - Street 2:SUITE 401
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-9229
Practice Address - Country:US
Practice Address - Phone:830-816-2611
Practice Address - Fax:830-816-2688
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11253672251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T2859OtherBCBS PROVIDER
TX00472XOtherMEDICARE GROUP UPIN
TX0084LJOtherBCBS GROUP
TX00472XOtherMEDICARE GROUP UPIN
TX8T2859OtherBCBS PROVIDER