MEDICARE: REVIVE HYDRATION SPA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225627920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE HYDRATION SPA LLC

Provider Business Mailing Address
First Line	:	5650 S FRANKLIN RD STE 300C
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46239-8620
Country	:	US
Telephone Number	:	317-245-7353
Fax Number	:	317-527-9214

Provider Business Practice Location Address
First Line	:	5650 S FRANKLIN RD STE 300C
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46239-8620
Country	:	US
Telephone Number	:	317-245-7353
Fax Number	:	317-527-9214

Authorized Official
Title or Position	:	OWNER
Name	:	JANE ARCHER
Credential	:	NP
Telephone Number	:	317-245-7353

Provider Enumeration Date	:	01/16/2021
Last Update Date	:	02/04/2025

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