Healthcare Provider Details

I. General information

NPI: 1891265773
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 CONCORD RD SE STE 200
SMYRNA GA
30080-4207
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 770-809-3036
  • Fax: 404-662-2399
Mailing address:
  • Phone: 770-809-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: TONIA RANA DAVIS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 770-809-3036