MEDICARE: EVERWELL MEDICAL ,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1902670870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERWELL MEDICAL ,LLC

Provider Business Mailing Address
First Line	:	2464 OLD FORT PKWY
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37128-4163
Country	:	US
Telephone Number	:	615-410-3137
Fax Number	:	615-410-3427

Provider Business Practice Location Address
First Line	:	2464 OLD FORT PKWY
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37128-4163
Country	:	US
Telephone Number	:	615-410-3137
Fax Number	:	615-410-3427

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. KO SAN CHAN
Credential	:
Telephone Number	:	615-609-5763

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	01/25/2024

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