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General NPI Number Information
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NPI Number | 1417731563
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Entity Type | Organization
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Legal Business Name | WELLSPRING GE INC
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Dates
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Enumeration Date | 08/21/2023
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 3886 PRINCETON LAKES WAY SW STE 120
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City | ATLANTA
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State | GA
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Zip | 30331-5511
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Country | US
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Telephone | 302-401-9193
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Fax |
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Provider Business Mailing Address
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Address Line | 3886 PRINCETON LAKES WAY SW STE 120
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City | ATLANTA
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State | GA
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Zip | 30331-5511
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Country | US
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Telephone | 302-401-9193
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOHN GREEN III
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Credential | MD
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Telephone | 302-401-9193
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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