Provider Demographics
NPI:1063047587
Name:ELITE INFUSION IV HYDRATION LLC
Entity type:Organization
Organization Name:ELITE INFUSION IV HYDRATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAVON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:267-516-8048
Mailing Address - Street 1:6136 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6136 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3704
Practice Address - Country:US
Practice Address - Phone:267-516-8048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty