Provider Demographics
NPI:1063061315
Name:WELLSTREET OF GEORGIA PC
Entity type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRED MGR
Authorized Official - Prefix:
Authorized Official - First Name:KEESHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PINACLE
Authorized Official - Suffix:
Authorized Official - Credentials:CREDENTIALING
Authorized Official - Phone:770-809-3036
Mailing Address - Street 1:3350 RIVERWOOD PKWY SE STE 1850
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3300
Mailing Address - Country:US
Mailing Address - Phone:770-809-3036
Mailing Address - Fax:404-662-2399
Practice Address - Street 1:1280 DOGWOOD DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5046
Practice Address - Country:US
Practice Address - Phone:404-994-4662
Practice Address - Fax:404-994-4663
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTREET OF GEORGIA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137211AMedicaid