Provider Demographics
NPI:1467249219
Name:AGELESS DYNAMICS LLC HYDRATE AND RENEW IV SOLUTIONS
Entity type:Organization
Organization Name:AGELESS DYNAMICS LLC HYDRATE AND RENEW IV SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:KHRISTINE
Authorized Official - Last Name:AXFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-971-0990
Mailing Address - Street 1:19757 THE PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-6608
Mailing Address - Country:US
Mailing Address - Phone:425-971-0990
Mailing Address - Fax:
Practice Address - Street 1:19757 THE PLACE BLVD
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-6608
Practice Address - Country:US
Practice Address - Phone:425-971-0990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty