Provider Demographics
NPI:1881990414
Name:WELLSTREET HOME THERAPY & MEDICAL
Entity type:Organization
Organization Name:WELLSTREET HOME THERAPY & MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:P
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-836-2240
Mailing Address - Street 1:16626 E AVENUE OF THE FOUNTAINS
Mailing Address - Street 2:STE. 102
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-8202
Mailing Address - Country:US
Mailing Address - Phone:480-836-2240
Mailing Address - Fax:480-836-2217
Practice Address - Street 1:16626 E AVENUE OF THE FOUNTAINS
Practice Address - Street 2:STE. 102
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-8202
Practice Address - Country:US
Practice Address - Phone:480-836-2240
Practice Address - Fax:480-836-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-29
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health