Healthcare Provider Details

I. General information

NPI: 1013809482
Provider Name (Legal Business Name): THE FRATERNITY MEN'S HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 POWDER SPRINGS ST STE B8
MARIETTA GA
30064-3560
US

IV. Provider business mailing address

540 POWDER SPRINGS ST STE B8
MARIETTA GA
30064-3560
US

V. Phone/Fax

Practice location:
  • Phone: 404-749-0571
  • Fax: 949-864-3686
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN SIMUEL BEASLEY III
Title or Position: OWNER/NURSE PRACTITIONER
Credential: NP
Phone: 404-749-0571