Healthcare Provider Details

I. General information

NPI: 1659061521
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56293 VAN DYKE AVE
SHELBY TOWNSHIP MI
48316-5019
US

IV. Provider business mailing address

56293 VAN DYKE AVE
SHELBY TOWNSHIP MI
48316-5019
US

V. Phone/Fax

Practice location:
  • Phone: 586-932-4539
  • Fax: 586-932-4570
Mailing address:
  • Phone: 586-932-4539
  • Fax: 586-932-4570

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: DISTRICT MANAGER
Credential:
Phone: 770-502-2121