Basic Information
| Provider Information | |||||||||
| NPI: | 1063061315 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSTREET OF GEORGIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 RIVERWOOD PKWY SE STE 1850 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708093036 | ||||||||
| FaxNumber: | 4046622399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1280 DOGWOOD DR SE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300135046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049944662 | ||||||||
| FaxNumber: | 4049944663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2019 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | PINACLE | ||||||||
| AuthorizedOfficialFirstName: | KEESHA | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CRED MGR | ||||||||
| AuthorizedOfficialTelephone: | 7708093036 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLSTREET OF GEORGIA PC | ||||||||
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| AuthorizedOfficialCredential: | CREDENTIALING | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 003137211A | 05 | GA | MEDICAID |