Provider Demographics
NPI:1063294155
Name:IV HYDRATION HEALTH & WELLNESS
Entity type:Organization
Organization Name:IV HYDRATION HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHACARYA
Authorized Official - Middle Name:KATORIA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:478-342-2400
Mailing Address - Street 1:6711 CHRISWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-6721
Mailing Address - Country:US
Mailing Address - Phone:478-342-2400
Mailing Address - Fax:
Practice Address - Street 1:617 CHERRY ST STE A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2880
Practice Address - Country:US
Practice Address - Phone:478-342-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1982317764Medicaid