MEDICARE: WELLSTREET OF GEORGIA PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1730611088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSTREET OF GEORGIA PC

Provider Business Mailing Address
First Line	:	3350 RIVERWOOD PKWY SE
Second Line	:	SUITE 1850
City	:	ATLANTA
State	:	GA
Zip	:	30339-6401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6660 ROSWELL RD
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-3167
Country	:	US
Telephone Number	:	404-996-0195
Fax Number	:	404-531-0967

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE CYCLE
Name	:	BRANDY CARTER
Credential	:
Telephone Number	:	404-996-0195

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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