Provider Demographics
NPI:1831371822
Name:WELLS, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:2450 GRASS LAKE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5613
Mailing Address - Country:US
Mailing Address - Phone:847-245-3202
Mailing Address - Fax:847-245-3203
Practice Address - Street 1:2450 GRASS LAKE RD
Practice Address - Street 2:SUITE D
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-5613
Practice Address - Country:US
Practice Address - Phone:847-245-3202
Practice Address - Fax:847-245-3203
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210841Medicare PIN
ILK14345Medicare UPIN