Provider Demographics
NPI:1659061521
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 1:56293 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-5019
Mailing Address - Country:US
Mailing Address - Phone:586-932-4539
Mailing Address - Fax:586-932-4570
Practice Address - Street 1:56293 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-5019
Practice Address - Country:US
Practice Address - Phone:586-932-4539
Practice Address - Fax:586-932-4570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site