MEDICARE: MELA URGENT AND PRIMARY CARE CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1598559726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELA URGENT AND PRIMARY CARE CLINIC LLC

Provider Business Mailing Address
First Line	:	953 MONTREAL RD STE B
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-1410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	953 MONTREAL RD STE B
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-1410
Country	:	US
Telephone Number	:	770-685-8821
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	MARSHET TENAW
Credential	:
Telephone Number	:	770-685-8821

Provider Enumeration Date	:	04/04/2025
Last Update Date	:	03/12/2026

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