Healthcare Provider Details

I. General information

NPI: 1043645914
Provider Name (Legal Business Name): HEALTHSTAT ON-SITE CLINIC/MILLIKEN KINGSLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2598 WASHINGTON RD
THOMSON GA
30824-6651
US

IV. Provider business mailing address

PO BOX 1433
PORTSMOUTH NH
03802-1433
US

V. Phone/Fax

Practice location:
  • Phone: 706-880-3120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JEFF WELLS
Title or Position: PRESIDENT
Credential: MD
Phone: 317-985-2111