Healthcare Provider Details

I. General information

NPI: 1164910253
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 REGENCY PARK DR STE 110
MCDONOUGH GA
30253-7076
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 404-996-0126
  • Fax:
Mailing address:
  • Phone: 770-809-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAMANTHA ALVORD
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-521-6690