Provider Demographics
NPI:1811708449
Name:WELLS, COLLIN RAY
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:RAY
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 BRACE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-4732
Mailing Address - Country:US
Mailing Address - Phone:313-770-4029
Mailing Address - Fax:
Practice Address - Street 1:6475 BRACE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-4732
Practice Address - Country:US
Practice Address - Phone:313-770-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1701048852174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist