Basic Information
| Provider Information | |||||||||
| NPI: | 1417581315 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELL SPRING HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 463 UPPER APPLEGATE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975309183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089690686 | ||||||||
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| Practice Location | |||||||||
| Address1: | 835 CRATER LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417737717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2020 | ||||||||
| LastUpdateDate: | 02/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | HANLEY | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2089690686 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 02/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.