Basic Information
| Provider Information | |||||||||
| NPI: | 1376113977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | WELLES | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1260 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917864982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099321069 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1260 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917864982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099321069 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2021 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.