Provider Demographics
NPI:1629863006
Name:BEWELL INTEGRATIVE HEALTH
Entity type:Organization
Organization Name:BEWELL INTEGRATIVE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:MIRANDA
Authorized Official - Last Name:RICKER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:229-800-8102
Mailing Address - Street 1:1095 US HIGHWAY 82 W
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5803
Mailing Address - Country:US
Mailing Address - Phone:229-800-8102
Mailing Address - Fax:229-800-8101
Practice Address - Street 1:1095 US HIGHWAY 82 W
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-5803
Practice Address - Country:US
Practice Address - Phone:229-800-8102
Practice Address - Fax:229-800-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-14
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty