Provider Demographics
NPI:1316515141
Name:WELLSTREET OF GEORGIA PC
Entity type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-770-9005
Mailing Address - Street 1:1825 HIGHWAY 34 E STE 1200
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6416
Mailing Address - Country:US
Mailing Address - Phone:470-851-3353
Mailing Address - Fax:
Practice Address - Street 1:880 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-292-9982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care