MEDICARE: THRIVEWELL LIFESTYLE MEDICINE PA

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1780407254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THRIVEWELL LIFESTYLE MEDICINE PA

Provider Business Mailing Address
First Line	:	817 BAMA BREEZE DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32124-3799
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	817 BAMA BREEZE DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32124-3799
Country	:	US
Telephone Number	:	386-488-1449
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GARY PITTS
Credential	:	MD
Telephone Number	:	386-488-1449

Provider Enumeration Date	:	11/04/2024
Last Update Date	:	11/04/2024

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