Provider Demographics
NPI:1992150296
Name:EB-WELLNESS PLLC
Entity type:Organization
Organization Name:EB-WELLNESS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:904-513-8892
Mailing Address - Street 1:13720 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:STE 8-260
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-7414
Mailing Address - Country:US
Mailing Address - Phone:904-513-8892
Mailing Address - Fax:
Practice Address - Street 1:13720 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:STE 8-260
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7414
Practice Address - Country:US
Practice Address - Phone:904-513-8892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5679133N00000X, 133NN1002X, 133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty