Basic Information
| Provider Information | |||||||||
| NPI: | 1538666854 | ||||||||
| 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: | 1575 MOUNT VERNON RD | ||||||||
| Address2: | |||||||||
| City: | DUNWOODY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303384146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049960197 | ||||||||
| FaxNumber: | 7707309969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2018 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | ALVORD | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7705216690 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 003135899A | 05 | GA | MEDICAID |