Provider Demographics
NPI:1932486131
Name:WELLSTAR HEALTH VENTURES, LLC
Entity Type:Organization
Organization Name:WELLSTAR HEALTH VENTURES, LLC
Other - Org Name:WELLSTAR ORTHOSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-644-0095
Mailing Address - Street 1:3450 ACWORTH DUE WEST RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1001
Mailing Address - Country:US
Mailing Address - Phone:770-974-7494
Mailing Address - Fax:770-974-9141
Practice Address - Street 1:3450 ACWORTH DUE WEST RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1001
Practice Address - Country:US
Practice Address - Phone:770-974-7494
Practice Address - Fax:770-974-9141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR HEALTH VENTURES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-16
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy