Healthcare Provider Details

I. General information

NPI: 1720930183
Provider Name (Legal Business Name): LIQUID LOUNGE HYDRATION DBA IDEAL VITALITY WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2026
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 PARK RD STE 2C
CHARLOTTE NC
28209-3748
US

IV. Provider business mailing address

5126 PARK RD STE 2C
CHARLOTTE NC
28209-3748
US

V. Phone/Fax

Practice location:
  • Phone: 704-247-7281
  • Fax: 704-800-5655
Mailing address:
  • Phone: 704-247-7281
  • Fax: 704-800-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER GUILLAUME
Title or Position: OPERATOR
Credential: BSN, RN
Phone: 704-247-7281