Provider Demographics
NPI:1740655448
Name:WELLS, MICHAEL (CPED)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 CHICAGO AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2378
Mailing Address - Country:US
Mailing Address - Phone:909-908-3920
Mailing Address - Fax:909-394-7411
Practice Address - Street 1:1835 CHICAGO AVE
Practice Address - Street 2:UNIT A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2378
Practice Address - Country:US
Practice Address - Phone:909-908-3920
Practice Address - Fax:909-394-7411
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPED3921224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7049390001Medicare NSC