Healthcare Provider Details

I. General information

NPI: 1952801128
Provider Name (Legal Business Name): RENEW HYDRATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 W MOCKINGBIRD LN STE 100
DALLAS TX
75235-5630
US

IV. Provider business mailing address

2601 W MOCKINGBIRD LN STE 100
DALLAS TX
75235-5630
US

V. Phone/Fax

Practice location:
  • Phone: 469-917-9166
  • Fax: 214-951-9720
Mailing address:
  • Phone: 469-917-9166
  • Fax: 214-951-9720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT GONZALEZ
Title or Position: CEO
Credential:
Phone: 214-837-8893