Healthcare Provider Details

I. General information

NPI: 1730843202
Provider Name (Legal Business Name): ELITE IV HYDRATION AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 PAVILION CT
MCDONOUGH GA
30253-6666
US

IV. Provider business mailing address

5916 EAST LAKE PKWY SUITE 324
MCDONOUGH GA
30253
US

V. Phone/Fax

Practice location:
  • Phone: 404-965-5715
  • Fax:
Mailing address:
  • Phone: 706-399-4601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. TANIKA RAMSEY POWELL
Title or Position: NURSE PRACTITIONER/OWNER
Credential: DND, APRN, NP-C
Phone: 706-399-4601