Healthcare Provider Details

I. General information

NPI: 1952139669
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 ARBOR SPRINGS TERRACE
NEWNAN GA
30265
US

IV. Provider business mailing address

35 ARBOR SPRINGS TERRACE
NEWNAN GA
30265
US

V. Phone/Fax

Practice location:
  • Phone: 470-323-5200
  • Fax: 470-323-5201
Mailing address:
  • Phone: 470-323-5200
  • Fax: 470-323-5201

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: DM
Credential:
Phone: 770-502-2121