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General NPI Number Information
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NPI Number | 1053100313
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Entity Type | Organization
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Legal Business Name | ESSENTIAL WELLNESS 360, LLC
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Dates
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Enumeration Date | 05/03/2025
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Last Update Date | 05/03/2025
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Provider Practice Location Address
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Address Line | 1281 MADO LOOP
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City | PALMETTO
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State | GA
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Zip | 30268-2465
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Country | US
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Telephone | 404-977-2599
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Fax |
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Provider Business Mailing Address
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Address Line | 10536 SERENBE LN
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City | PALMETTO
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State | GA
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Zip | 30268-2290
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Country | US
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Telephone | 678-524-7265
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Fax |
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Authorized Official
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Title or Position | FOUNDER/CEO
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Name | MRS. GERENDA ANYA WILBORN
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Credential | RN
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Telephone | 678-524-7265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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