MEDICARE: WELLSTREET OF GEORGIA PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1093596579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSTREET OF GEORGIA PC

Provider Business Mailing Address
First Line	:	1300 SOM CENTER RD
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-2048
Country	:	US
Telephone Number	:	440-210-4140
Fax Number	:	440-210-4145

Provider Business Practice Location Address
First Line	:	1300 SOM CENTER RD
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-2048
Country	:	US
Telephone Number	:	440-210-4140
Fax Number	:	440-210-4145

Authorized Official
Title or Position	:	DISTRICT MANAGER
Name	:	KATIE MONS
Credential	:
Telephone Number	:	770-502-2121

Provider Enumeration Date	:	10/10/2023
Last Update Date	:	10/18/2023

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Directions to “WELLSTREET OF GEORGIA PC ” Practice Location

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