MEDICARE: PURE HYDRATION & WELLNESS 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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1770201501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE HYDRATION & WELLNESS LLC

Provider Business Mailing Address
First Line	:	2850 S ARLINGTON RD STE 102
Second Line	:
City	:	COVENTRY TOWNSHIP
State	:	OH
Zip	:	44312-4719
Country	:	US
Telephone Number	:	234-280-2550
Fax Number	:	234-280-2570

Provider Business Practice Location Address
First Line	:	2850 S ARLINGTON RD STE 102
Second Line	:
City	:	COVENTRY TOWNSHIP
State	:	OH
Zip	:	44312-4719
Country	:	US
Telephone Number	:	234-280-2550
Fax Number	:	234-280-2570

Authorized Official
Title or Position	:	OWNER
Name	:	TIARA BROADY
Credential	:	NP
Telephone Number	:	234-280-2550

Provider Enumeration Date	:	08/18/2022
Last Update Date	:	07/07/2025

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