MEDICARE: IV LEAGUE HYDRATION THERAPY 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	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1811620016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IV LEAGUE HYDRATION THERAPY LLC

Provider Business Mailing Address
First Line	:	3709 W JETTON AVE STE A1
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5115
Country	:	US
Telephone Number	:	813-769-9127
Fax Number	:

Provider Business Practice Location Address
First Line	:	2122 S DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-6312
Country	:	US
Telephone Number	:	813-769-9127
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. SIDNEY BRADLEY
Credential	:
Telephone Number	:	813-769-9127

Provider Enumeration Date	:	07/05/2022
Last Update Date	:	07/05/2022

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