Basic Information
| Provider Information | |||||||||
| NPI: | 1366023764 | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1524 LAFAYETTE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302412566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065302151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | CASSARINO | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4704003449 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLSTREET OF GEORGIA PC | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.