Healthcare Provider Details

I. General information

NPI: 1013798594
Provider Name (Legal Business Name): WELLSTREET OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 08/08/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36320 DETROIT ROAD SUITE 100
AVON OH
44011-2834
US

IV. Provider business mailing address

1997 HEALTHWAY DR STE 101
AVON OH
44011-2834
US

V. Phone/Fax

Practice location:
  • Phone: 440-540-4200
  • Fax: 440-540-4250
Mailing address:
  • Phone: 440-540-4200
  • Fax: 440-540-4250

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