=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720969736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REWILD NATURAL HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2025
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2560 E MAIN ST STE 2A
-----------------------------------------------------
City | REEDSBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53959-9472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-768-2250
-----------------------------------------------------
Fax | 608-768-2251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2560 E MAIN ST STE 2A
-----------------------------------------------------
City | REEDSBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53959-9472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-768-2250
-----------------------------------------------------
Fax | 608-768-2251
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MORGAN RACHAEL FULTON
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 608-768-2250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------