Provider Demographics
NPI:1588390868
Name:WELLSTREET OF GEORGIA PC
Entity type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-414-2824
Mailing Address - Street 1:1305 JENNINGS MILL RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7241
Mailing Address - Country:US
Mailing Address - Phone:706-410-2005
Mailing Address - Fax:
Practice Address - Street 1:1305 JENNINGS MILL RD STE 120
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7241
Practice Address - Country:US
Practice Address - Phone:706-410-2005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site