Provider Demographics
NPI:1043788425
Name:HANGOVER IV & BEAUTY THERAPY
Entity type:Organization
Organization Name:HANGOVER IV & BEAUTY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GODINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-774-3443
Mailing Address - Street 1:17977 KEYLIME BLVD
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470
Mailing Address - Country:US
Mailing Address - Phone:561-774-3443
Mailing Address - Fax:561-630-6011
Practice Address - Street 1:4600 MILITARY TRL STE 110
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-4811
Practice Address - Country:US
Practice Address - Phone:561-774-3443
Practice Address - Fax:561-630-6011
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURE IV THERAPY HEALTH & WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service