Provider Demographics
NPI:1003561614
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 1:3999 AUSTELL RD STE 901
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1160
Mailing Address - Country:US
Mailing Address - Phone:770-809-3032
Mailing Address - Fax:678-838-6797
Practice Address - Street 1:3999 AUSTELL RD STE 901
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1160
Practice Address - Country:US
Practice Address - Phone:770-809-3032
Practice Address - Fax:678-838-6797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site