MEDICARE: THE HEALTHY HIVE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	114230	TX

General Provider Information

NPI Number	:	1518491471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HEALTHY HIVE, LLC

Provider Business Mailing Address
First Line	:	771 AN COUNTY ROAD 142
Second Line	:
City	:	PALESTINE
State	:	TX
Zip	:	75801-6313
Country	:	US
Telephone Number	:	903-316-6386
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 E COMMERCE ST
Second Line	:	SUITE 209
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-4970
Country	:	US
Telephone Number	:	903-316-6386
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST/ OWNER
Name	:	NIKKI BYBEE GOODALE
Credential	:	OTR,CLT
Telephone Number	:	903-316-6386

Provider Enumeration Date	:	04/18/2017
Last Update Date	:	04/18/2017

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