Healthcare Provider Details

I. General information

NPI: 1235411547
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
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

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

V. Phone/Fax

Practice location:
  • Phone: 770-502-2121
  • Fax: 770-502-2113
Mailing address:
  • Phone: 404-996-0344
  • Fax: 404-662-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VICTORIA ELLISON
Title or Position: VICE PRESIDENT REVENUE CYCLE MANAGE
Credential:
Phone: 770-502-2121