Provider Demographics
NPI:1598547192
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 1:4282 BELLS FERRY RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1302
Mailing Address - Country:US
Mailing Address - Phone:678-701-4125
Mailing Address - Fax:678-701-4126
Practice Address - Street 1:4282 BELLS FERRY RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1302
Practice Address - Country:US
Practice Address - Phone:678-701-4125
Practice Address - Fax:678-701-4126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site