MEDICARE: GEN 3 IV HYDRATION AND WELLNESS

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1598572059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEN 3 IV HYDRATION AND WELLNESS

Provider Business Mailing Address
First Line	:	1210 NE CORONADO DR
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-2928
Country	:	US
Telephone Number	:	816-661-0335
Fax Number	:	816-552-1228

Provider Business Practice Location Address
First Line	:	418 NW LEGACY DR
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-2894
Country	:	US
Telephone Number	:	816-599-0053
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER MAXEY
Credential	:	RN
Telephone Number	:	816-560-2286

Provider Enumeration Date	:	12/17/2024
Last Update Date	:	12/17/2024

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