Provider Demographics
NPI:1538666854
Name:WELLSTREET OF GEORGIA PC
Entity Type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-521-6690
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:770-809-3036
Mailing Address - Fax:404-662-2399
Practice Address - Street 1:1575 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4146
Practice Address - Country:US
Practice Address - Phone:404-996-0197
Practice Address - Fax:770-730-9969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135899AMedicaid