Healthcare Provider Details

I. General information

NPI: 1487126637
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 12/28/2018
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: 678-600-5137
  • Fax: 678-600-5098
Mailing address:
  • Phone: 770-809-3036
  • Fax:

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: KEESHA D. PINACLE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 770-809-3036