Healthcare Provider Details

I. General information

NPI: 1487249769
Provider Name (Legal Business Name): EVERGREEN WELLNESS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 BETHANY OAKS POINTE
ALPHARETTA GA
30004-4319
US

IV. Provider business mailing address

13800 BETHANY OAKS POINTE
ALPHARETTA GA
30004-4319
US

V. Phone/Fax

Practice location:
  • Phone: 678-761-2408
  • Fax:
Mailing address:
  • Phone: 678-761-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA HOSEA
Title or Position: OWNER
Credential: RN
Phone: 678-791-2408