Provider Demographics
NPI:1477098663
Name:HYDRATION CLINICS OF AMERICA
Entity Type:Organization
Organization Name:HYDRATION CLINICS OF AMERICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FANTASIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:856-489-0555
Mailing Address - Street 1:538 LIPPINCOTT DR
Mailing Address - Street 2:BLG E
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4806
Mailing Address - Country:US
Mailing Address - Phone:856-489-0555
Mailing Address - Fax:856-489-0505
Practice Address - Street 1:538 LIPPINCOTT DR
Practice Address - Street 2:BLG E
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4806
Practice Address - Country:US
Practice Address - Phone:856-489-0555
Practice Address - Fax:856-489-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05610900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ12352000775OtherUPIN