1114666203 NPI number — IVY DRIP IV HYDRATION, AESTHETICS, AND WEIGHT LOSS

Table of content: (NPI 1114666203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114666203 NPI number — IVY DRIP IV HYDRATION, AESTHETICS, AND WEIGHT LOSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVY DRIP IV HYDRATION, AESTHETICS, AND WEIGHT LOSS
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1114666203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5330 FRY RD
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
KATY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5330 FRY RD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
KATY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-721-2629
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
CAINS-BARNES
Authorized Official First Name:
LATOYA
Authorized Official Middle Name:
Authorized Official Title or Position:
FNP-C
Authorized Official Telephone Number:
832-721-2629

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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