Healthcare Provider Details

I. General information

NPI: 1003561614
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 02/14/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3999 AUSTELL RD STE 901
AUSTELL GA
30106-1160
US

IV. Provider business mailing address

3999 AUSTELL RD STE 901
AUSTELL GA
30106-1160
US

V. Phone/Fax

Practice location:
  • Phone: 770-809-3032
  • Fax: 678-838-6797
Mailing address:
  • Phone: 770-809-3032
  • Fax: 678-838-6797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: KATIE CASSARINO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 678-414-2824