Healthcare Provider Details

I. General information

NPI: 1265363337
Provider Name (Legal Business Name): KGR HEALTH AND WELLNESS ACADEMY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 FESMIRE ST
ASHEBORO NC
27205-7723
US

IV. Provider business mailing address

747 FESMIRE ST
ASHEBORO NC
27205-7723
US

V. Phone/Fax

Practice location:
  • Phone: 984-364-9513
  • Fax:
Mailing address:
  • Phone: 984-364-9513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: RAE RITTER
Title or Position: DIRECTOR OF OUTREACH AND IT
Credential: NBC-HWC
Phone: 984-364-9513