Provider Demographics
NPI:1700097151
Name:BOVARD, WELLS (LAC)
Entity Type:Individual
Prefix:
First Name:WELLS
Middle Name:
Last Name:BOVARD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 COLUMBUS AVENUE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3501
Mailing Address - Country:US
Mailing Address - Phone:612-220-4581
Mailing Address - Fax:
Practice Address - Street 1:18142 MINNETONKA BLVD.
Practice Address - Street 2:
Practice Address - City:DEEPHAVEN
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-345-3335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1311171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist