=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427968668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RISE WELLNESS AND LONGEVITY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2026
-----------------------------------------------------
Last Update Date | 09/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427A N MAIN ST
-----------------------------------------------------
City | PRINEVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97754-1855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-903-2758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 427A N MAIN ST
-----------------------------------------------------
City | PRINEVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97754-1855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-903-2758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/HEALTH COACH
-----------------------------------------------------
Name | JEREMY HICKS
-----------------------------------------------------
Credential | ISSA NUTRITION COACH
-----------------------------------------------------
Telephone | 541-903-2758
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------