Provider Demographics
NPI:1811620016
Name:IV LEAGUE HYDRATION THERAPY LLC
Entity Type:Organization
Organization Name:IV LEAGUE HYDRATION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-769-9127
Mailing Address - Street 1:3709 W JETTON AVE STE A1
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5115
Mailing Address - Country:US
Mailing Address - Phone:813-769-9127
Mailing Address - Fax:
Practice Address - Street 1:2122 S DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6312
Practice Address - Country:US
Practice Address - Phone:813-769-9127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty