Provider Demographics
NPI:1508239997
Name:WELLSTREET OF GEORGIA PC
Entity Type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-809-3036
Mailing Address - Street 1:549 BULLSBORO DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1045
Mailing Address - Country:US
Mailing Address - Phone:770-502-2121
Mailing Address - Fax:
Practice Address - Street 1:1825 HIGHWAY 34 E STE 1200
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6416
Practice Address - Country:US
Practice Address - Phone:770-502-2121
Practice Address - Fax:770-502-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-06
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center