Provider Demographics
NPI:1619624681
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:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSARINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-414-2824
Mailing Address - Street 1:4475 W VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2869
Mailing Address - Country:US
Mailing Address - Phone:770-507-7950
Mailing Address - Fax:770-507-7978
Practice Address - Street 1:4475 W VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2869
Practice Address - Country:US
Practice Address - Phone:770-507-7950
Practice Address - Fax:770-507-7978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site