Provider Demographics
NPI:1053100313
Name:ESSENTIAL WELLNESS 360, LLC
Entity type:Organization
Organization Name:ESSENTIAL WELLNESS 360, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERENDA
Authorized Official - Middle Name:ANYA
Authorized Official - Last Name:WILBORN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:678-524-7265
Mailing Address - Street 1:10536 SERENBE LN
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-2290
Mailing Address - Country:US
Mailing Address - Phone:678-524-7265
Mailing Address - Fax:
Practice Address - Street 1:1281 MADO LOOP
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-2465
Practice Address - Country:US
Practice Address - Phone:404-977-2599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-03
Last Update Date:2025-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty