Provider Demographics
NPI:1073742482
Name:WELLSTAR PEDIATRIC & FAMILY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:WELLSTAR PEDIATRIC & FAMILY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST; VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-792-5261
Mailing Address - Street 1:1810 MULKEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1151
Mailing Address - Country:US
Mailing Address - Phone:770-634-2349
Mailing Address - Fax:770-819-0597
Practice Address - Street 1:1810 MULKEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1151
Practice Address - Country:US
Practice Address - Phone:770-634-2349
Practice Address - Fax:770-819-0597
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty