Healthcare Provider Details

I. General information

NPI: 1508239997
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2015
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 HIGHWAY 34 E STE 1200
NEWNAN GA
30265-6416
US

IV. Provider business mailing address

549 BULLSBORO DR
NEWNAN GA
30265-1045
US

V. Phone/Fax

Practice location:
  • Phone: 770-502-2121
  • Fax: 770-502-2113
Mailing address:
  • Phone: 770-502-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONIA R DAVIS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 770-809-3036