Provider Demographics
NPI:1366105355
Name:ULTIMATE HYDRATION AND WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:ULTIMATE HYDRATION AND WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FOLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSIBANJO
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:203-450-3051
Mailing Address - Street 1:1905 WOODSTOCK RD STE 6100
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-5630
Mailing Address - Country:US
Mailing Address - Phone:470-285-2750
Mailing Address - Fax:678-404-5104
Practice Address - Street 1:1905 WOODSTOCK RD STE 6100
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5630
Practice Address - Country:US
Practice Address - Phone:470-285-2750
Practice Address - Fax:678-404-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy