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General NPI Number Information
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NPI Number | 1366105355
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Entity Type | Organization
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Legal Business Name | ULTIMATE HYDRATION AND WELLNESS CLINIC LLC
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Dates
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Enumeration Date | 10/18/2021
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Last Update Date | 10/18/2021
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Provider Practice Location Address
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Address Line | 1905 WOODSTOCK RD STE 6100
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City | ROSWELL
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State | GA
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Zip | 30075-5630
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Country | US
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Telephone | 470-285-2750
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Fax | 678-404-5104
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Provider Business Mailing Address
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Address Line | 1905 WOODSTOCK RD STE 6100
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City | ROSWELL
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State | GA
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Zip | 30075-5630
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Country | US
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Telephone | 470-285-2750
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Fax | 678-404-5104
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | FOLAKE OSIBANJO
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Credential | NP-C
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Telephone | 203-450-3051
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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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