MEDICARE: LIQUID LOUNGE HYDRATION DBA IDEAL VITALITY 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	251J00000X	Nursing Care Agency
2	246QL0900X	Laboratory Management Specialist/Technologist

General Provider Information

NPI Number	:	1720930183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIQUID LOUNGE HYDRATION DBA IDEAL VITALITY WELLNESS

Provider Business Mailing Address
First Line	:	5126 PARK RD STE 2C
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3748
Country	:	US
Telephone Number	:	704-247-7281
Fax Number	:	704-800-5655

Provider Business Practice Location Address
First Line	:	5126 PARK RD STE 2C
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3748
Country	:	US
Telephone Number	:	704-247-7281
Fax Number	:	704-800-5655

Authorized Official
Title or Position	:	OPERATOR
Name	:	JENNIFER GUILLAUME
Credential	:	BSN, RN
Telephone Number	:	704-247-7281

Provider Enumeration Date	:	02/10/2026
Last Update Date	:	02/10/2026

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