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General NPI Number Information
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NPI Number | 1699419432
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Entity Type | Organization
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Legal Business Name | WELLSTREET OF GEORGIA PC
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Dates
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Enumeration Date | 04/27/2022
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Last Update Date | 04/27/2022
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Provider Practice Location Address
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Address Line | 2410 INGLESIDE AVE
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City | MACON
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State | GA
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Zip | 31204-2036
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Country | US
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Telephone | 478-309-1004
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Fax | 478-309-2396
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Provider Business Mailing Address
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Address Line | 2410 INGLESIDE AVE
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City | MACON
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State | GA
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Zip | 31204-2036
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Country | US
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Telephone | 478-309-1004
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Fax | 478-309-2396
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | KATIE CASSARINO
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Credential |
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Telephone | 678-414-2824
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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