Provider Demographics
NPI:1245998079
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:KATHARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSARINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-414-2824
Mailing Address - Street 1:3350 RIVERWOOD PKWY SE STE 1850
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2976 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1733
Practice Address - Country:US
Practice Address - Phone:912-225-5325
Practice Address - Fax:912-243-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site