Provider Demographics
NPI:1093596579
Name:WELLSTREET OF GEORGIA PC
Entity Type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-502-2121
Mailing Address - Street 1:1300 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2048
Mailing Address - Country:US
Mailing Address - Phone:440-210-4140
Mailing Address - Fax:440-210-4145
Practice Address - Street 1:1300 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2048
Practice Address - Country:US
Practice Address - Phone:440-210-4140
Practice Address - Fax:440-210-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site