Healthcare Provider Details

I. General information

NPI: 1659666337
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 SANDY PLAINS RD
MARIETTA GA
30066-3020
US

IV. Provider business mailing address

3600 SANDY PLAINS RD
MARIETTA GA
30066-3020
US

V. Phone/Fax

Practice location:
  • Phone: 770-977-4547
  • Fax: 770-977-8354
Mailing address:
  • Phone: 770-977-4547
  • Fax: 770-977-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

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