Healthcare Provider Details

I. General information

NPI: 1376226464
Provider Name (Legal Business Name): DOVE HYDRATION & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N 35TH ST FL 2
MILWAUKEE WI
53208-3318
US

IV. Provider business mailing address

950 N 35TH ST FL 2
MILWAUKEE WI
53208-3318
US

V. Phone/Fax

Practice location:
  • Phone: 414-775-7739
  • Fax:
Mailing address:
  • Phone: 414-775-7739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LILLIAN MORENIKE ODUWOLE
Title or Position: DIRECTOR / OWNER
Credential:
Phone: 414-775-7739