Provider Demographics
NPI:1538647441
Name:WELLSTREET OF GEORGIA PC
Entity Type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:PIEDMONT URGENTCARE BY WELLSTREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEESHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PINACLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-809-3036
Mailing Address - Street 1:3350 RIVERWOOD PKWY SE STE 1850
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3300
Mailing Address - Country:US
Mailing Address - Phone:140-466-2239
Mailing Address - Fax:
Practice Address - Street 1:5239 HIGHWAY 278 NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2671
Practice Address - Country:US
Practice Address - Phone:678-660-5106
Practice Address - Fax:678-660-5107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site