Healthcare Provider Details

I. General information

NPI: 1720965700
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 HIGHWAY 42 S STE 100
LOCUST GROVE GA
30248-3014
US

IV. Provider business mailing address

3366 HIGHWAY 42 S STE 100
LOCUST GROVE GA
30248-3014
US

V. Phone/Fax

Practice location:
  • Phone: 470-759-2085
  • Fax: 470-759-2090
Mailing address:
  • Phone: 470-759-2085
  • Fax: 470-759-2090

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 MONS
Title or Position: DISTRICT MANAGER
Credential:
Phone: 770-502-2121