Provider Demographics
NPI:1275293656
Name:EGREEN ENTERPRISES, INC
Entity Type:Organization
Organization Name:EGREEN ENTERPRISES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWAGGARD-GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:R, PH
Authorized Official - Phone:716-308-6266
Mailing Address - Street 1:5072 CHAPEL LAKE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:716-308-6266
Mailing Address - Fax:
Practice Address - Street 1:3150 GOLF RIDGE BLDVD
Practice Address - Street 2:SUITE 101
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:770-990-3335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory