Provider Demographics
NPI:1881363927
Name:WELLSPRING HEALTHCARE LLC
Entity type:Organization
Organization Name:WELLSPRING HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:HAAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-815-3324
Mailing Address - Street 1:705B SE MELODY LN # 184
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-4380
Mailing Address - Country:US
Mailing Address - Phone:909-815-3324
Mailing Address - Fax:
Practice Address - Street 1:6124 RAYTOWN RD
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4007
Practice Address - Country:US
Practice Address - Phone:909-815-3324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-11
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty