Healthcare Provider Details

I. General information

NPI: 1205883329
Provider Name (Legal Business Name): WELLSTAR PEDIATRIC & ADOLESCENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 MULKEY RD SUITE 201
AUSTELL GA
30106-1151
US

IV. Provider business mailing address

1810 MULKEY RD SUITE 201
AUSTELL GA
30106-1151
US

V. Phone/Fax

Practice location:
  • Phone: 770-819-9262
  • Fax: 678-945-1295
Mailing address:
  • Phone: 770-819-9262
  • Fax: 678-945-1295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE ASHE
Title or Position: EXECUTIVE DIRECTOR OF FINANCE
Credential:
Phone: 770-792-5261