=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629863006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEWELL INTEGRATIVE HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2025
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1095 US HIGHWAY 82 W
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31763-5803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-800-8102
-----------------------------------------------------
Fax | 229-800-8101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1095 US HIGHWAY 82 W
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31763-5803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-800-8102
-----------------------------------------------------
Fax | 229-800-8101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. GAIL MIRANDA RICKER
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 229-800-8102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------