Healthcare Provider Details

I. General information

NPI: 1043688138
Provider Name (Legal Business Name): BWELL4EVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 VANCE RD STE 106
CHATTANOOGA TN
37421-3665
US

IV. Provider business mailing address

7476 NASHVILLE ST
RINGGOLD GA
30736-2358
US

V. Phone/Fax

Practice location:
  • Phone: 423-531-9355
  • Fax: 423-531-9356
Mailing address:
  • Phone: 706-935-3055
  • Fax: 706-935-3056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number621999
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARLENE GEREN
Title or Position: OWNER
Credential: RN
Phone: 423-531-9355