=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588546998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWEET LIFE WELLNESS DIRECT PRIMARY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2025
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4525 INTELCO LOOP SE STE 205
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-472-4785
-----------------------------------------------------
Fax | 360-299-6116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 944
-----------------------------------------------------
City | EAST OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98540-0944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-472-4785
-----------------------------------------------------
Fax | 360-299-6116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. BETHANY SWEET
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 360-472-4785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------