Healthcare Provider Details

I. General information

NPI: 1194571026
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 PAVILLION PKWY
MONROE GA
30656-5012
US

IV. Provider business mailing address

850 PAVILLION PKWY
MONROE GA
30656-5012
US

V. Phone/Fax

Practice location:
  • Phone: 678-395-0010
  • Fax: 678-395-0020
Mailing address:
  • Phone: 678-395-0010
  • Fax: 678-395-0020

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