=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013859925
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE HEALTHCARE FUNCTIONAL & INTEGRATIVE MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2026
-----------------------------------------------------
Last Update Date | 04/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1961 HIGHWAY 42 N
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-4729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-286-6597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1961 HIGHWAY 42 N
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-4729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-286-6597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CANDACE LEWIS
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 678-615-5710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------