Healthcare Provider Details

I. General information

NPI: 1629863006
Provider Name (Legal Business Name): BEWELL INTEGRATIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 US HIGHWAY 82 W
LEESBURG GA
31763-5803
US

IV. Provider business mailing address

1095 US HIGHWAY 82 W
LEESBURG GA
31763-5803
US

V. Phone/Fax

Practice location:
  • Phone: 229-800-8102
  • Fax: 229-800-8101
Mailing address:
  • Phone: 229-800-8102
  • Fax: 229-800-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. GAIL MIRANDA RICKER
Title or Position: OWNER
Credential: NP-C
Phone: 229-800-8102