Healthcare Provider Details

I. General information

NPI: 1063061315
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 DOGWOOD DR SE
CONYERS GA
30013-5046
US

IV. Provider business mailing address

3350 RIVERWOOD PKWY SE STE 1850
ATLANTA GA
30339-3300
US

V. Phone/Fax

Practice location:
  • Phone: 404-994-4662
  • Fax: 404-994-4663
Mailing address:
  • Phone: 770-809-3036
  • Fax: 404-662-2399

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: KEESHA D. PINACLE
Title or Position: CRED MGR
Credential: CREDENTIALING
Phone: 770-809-3036