Provider Demographics
NPI:1972669661
Name:HEALTHWELL MEDICAL GROUP
Entity Type:Organization
Organization Name:HEALTHWELL MEDICAL GROUP
Other - Org Name:HEALTHWELL MEDICAL GROUP DE BELEN PC
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANO DEBELEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-894-9422
Mailing Address - Street 1:PO BOX 82277
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89180
Mailing Address - Country:US
Mailing Address - Phone:702-894-9422
Mailing Address - Fax:702-894-9258
Practice Address - Street 1:4375 S BUFFALO DR
Practice Address - Street 2:#101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147
Practice Address - Country:US
Practice Address - Phone:702-894-9422
Practice Address - Fax:702-894-9258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10005207R00000X
NV10006208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G21857Medicare UPIN
G90093Medicare UPIN
36229Medicare ID - Type Unspecified
36228Medicare ID - Type Unspecified
37581Medicare ID - Type Unspecified
37558Medicare ID - Type Unspecified