# WELLINGTON PROVIDER GROUP PC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** WELLINGTON PROVIDER GROUP PC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1669184651
- **Legal business name:** WELLINGTON PROVIDER GROUP PC
- **Authorized official:** MARIELA BRAVO (CREDENTIALING TEAM LEAD)
- **Authorized official phone:** (859) 518-8817

## Contact information

- **Practice address:** 1299 FARNAM ST STE 300, OMAHA, NE 68102-1857
- **Practice address phone:** (859) 518-8817
- **Practice address fax:** (859) 201-1084
- **Mailing address:** 535 WELLINGTON WAY STE 330, LEXINGTON, KY 40503-1331
- **Mailing address phone:** (859) 518-8817
- **Mailing address fax:** (859) 201-1084

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 12/21/2022
- **Last updated:** 12/21/2022