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General NPI Number Information
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NPI Number | 1144899642
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Entity Type | Organization
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Legal Business Name | I-VITA HYDRATION AND WELLNESS LOUNGE LLC
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Dates
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Enumeration Date | 06/21/2021
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Last Update Date | 07/02/2021
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Provider Practice Location Address
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Address Line | 425 BRECKENRIDGE CIR SE
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City | PALM BAY
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State | FL
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Zip | 32909-2341
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Country | US
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Telephone | 321-215-8304
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Fax |
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Provider Business Mailing Address
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Address Line | 425 BRECKENRIDGE CIR SE
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City | PALM BAY
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State | FL
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Zip | 32909-2341
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Country | US
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Telephone | 321-215-8304
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MILTIYIA BLAIN
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Credential | BSN, RN
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Telephone | 321-215-8304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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