Provider Demographics
NPI:1013246222
Name:GREEN WELLS EECP PHYSICAL THERAPY
Entity Type:Organization
Organization Name:GREEN WELLS EECP PHYSICAL THERAPY
Other - Org Name:GREEN WELLS EECP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIEF TECHICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-405-1478
Mailing Address - Street 1:8602 ELBURG ST UNIT C
Mailing Address - Street 2:7136 PACIFIC BLVD SUITE 220
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-8632
Mailing Address - Country:US
Mailing Address - Phone:323-588-5467
Mailing Address - Fax:323-589-6662
Practice Address - Street 1:8602 ELBURG STREET APT C
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723
Practice Address - Country:US
Practice Address - Phone:310-405-1478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities