Provider Demographics
NPI:1730232075
Name:THERON WELLS MD INCORPORATED
Entity type:Organization
Organization Name:THERON WELLS MD INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-MD
Authorized Official - Prefix:
Authorized Official - First Name:THERON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-371-9391
Mailing Address - Street 1:PO BOX 2377
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-2377
Mailing Address - Country:US
Mailing Address - Phone:951-371-9391
Mailing Address - Fax:951-346-9040
Practice Address - Street 1:730 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3117
Practice Address - Country:US
Practice Address - Phone:951-371-9391
Practice Address - Fax:951-346-9040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69274101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF57132Medicare UPIN