Healthcare Provider Details

I. General information

NPI: 1992150296
Provider Name (Legal Business Name): EB-WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13720 OLD SAINT AUGUSTINE RD STE 8-260
JACKSONVILLE FL
32258-7414
US

IV. Provider business mailing address

13720 OLD SAINT AUGUSTINE RD STE 8-260
JACKSONVILLE FL
32258-7414
US

V. Phone/Fax

Practice location:
  • Phone: 904-513-8892
  • Fax:
Mailing address:
  • Phone: 904-513-8892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND 5679
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberND 5679
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberND 5679
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 5679
License Number StateFL

VIII. Authorized Official

Name: MRS. ELAINE ANN BEVILLE
Title or Position: AUTHORIZED MEMBER
Credential: MS, RD, LDN
Phone: 904-513-8892