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General NPI Number Information
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NPI Number | 1720930183
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Entity Type | Organization
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Legal Business Name | LIQUID LOUNGE HYDRATION DBA IDEAL VITALITY WELLNESS
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Dates
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Enumeration Date | 02/10/2026
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Last Update Date | 02/10/2026
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Provider Practice Location Address
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Address Line | 5126 PARK RD STE 2C
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City | CHARLOTTE
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State | NC
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Zip | 28209-3748
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Country | US
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Telephone | 704-247-7281
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Fax | 704-800-5655
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Provider Business Mailing Address
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Address Line | 5126 PARK RD STE 2C
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City | CHARLOTTE
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State | NC
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Zip | 28209-3748
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Country | US
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Telephone | 704-247-7281
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Fax | 704-800-5655
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Authorized Official
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Title or Position | OPERATOR
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Name | JENNIFER GUILLAUME
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Credential | BSN, RN
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Telephone | 704-247-7281
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 246QL0900X
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Taxonomy Name | Laboratory Management Specialist/Technologist
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License Number |
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License Number State |
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