Provider Demographics
NPI:1366787194
Name:WELLCREST
Entity type:Organization
Organization Name:WELLCREST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:IRIS
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:781-639-2260
Mailing Address - Street 1:238 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-3367
Mailing Address - Country:US
Mailing Address - Phone:781-639-2260
Mailing Address - Fax:781-348-6414
Practice Address - Street 1:238 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-3367
Practice Address - Country:US
Practice Address - Phone:781-639-2260
Practice Address - Fax:781-348-6414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty