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General NPI Number Information
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NPI Number | 1730843202
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Entity Type | Organization
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Legal Business Name | ELITE IV HYDRATION AND WELLNESS
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Dates
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Enumeration Date | 10/29/2021
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Last Update Date | 06/30/2023
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Provider Practice Location Address
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Address Line | 823 PAVILION CT
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City | MCDONOUGH
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State | GA
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Zip | 30253-6666
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Country | US
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Telephone | 404-965-5715
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Fax |
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Provider Business Mailing Address
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Address Line | 5916 EAST LAKE PKWY SUITE 324
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City | MCDONOUGH
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State | GA
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Zip | 30253
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Country | US
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Telephone | 706-399-4601
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER/OWNER
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Name | MRS. TANIKA RAMSEY POWELL
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Credential | DND, APRN, NP-C
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Telephone | 706-399-4601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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