Organization
IV HYDRATION VITAMIN THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANDREA FAST (MANAGER)
(765) 730-2130
Entity
Organization
Contact information
Practice address
10020 AUBURN PARK DR STE A, FORT WAYNE, IN 46825-2389
(260) 705-7457
Mailing address
2624 BARRY KNOLL WAY, FORT WAYNE, IN 46845-1938
Taxonomy
Speciality
Code
Description
License number
State
163WI0500X
Infusion Therapy Registered Nurse
—
—
207P00000X
Emergency Medicine Physician
—
—
261QH0100X
Health Service Clinic/Center
—
—
261QI0500X
Infusion Therapy Clinic/Center
Primary
—
—
363L00000X
Nurse Practitioner
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1598785149
NPI
IN
01
—
1790220101
NPI
IN
01
—
1881049161
NPI
IN
Enumeration date
11/14/2022
Last updated
11/29/2022
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