Healthcare Provider Details

I. General information

NPI: 1083557268
Provider Name (Legal Business Name): EVERGREEN MOBILE PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 TENCH RD STE 1020
SUWANEE GA
30024-6741
US

IV. Provider business mailing address

2245 WISTERIA DR STE 200-1154
SNELLVILLE GA
30078-3798
US

V. Phone/Fax

Practice location:
  • Phone: 770-265-0864
  • Fax: 770-264-1879
Mailing address:
  • Phone: 770-265-0864
  • Fax: 770-264-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OLUSEUN AYODELE BABATUNDE
Title or Position: MANAGING MEMBER
Credential: FNP-BC
Phone: 770-265-0864