Provider Demographics
NPI:1811412091
Name:H2O:HEALTH HYDRATION OASIS
Entity Type:Organization
Organization Name:H2O:HEALTH HYDRATION OASIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALIA
Authorized Official - Middle Name:LYNELL
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-998-0683
Mailing Address - Street 1:13130 WATERTOWN PLANK RD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2240
Mailing Address - Country:US
Mailing Address - Phone:269-998-0683
Mailing Address - Fax:
Practice Address - Street 1:17110 W GREENFIELD AVE STE 6
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6899
Practice Address - Country:US
Practice Address - Phone:269-998-0683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55919-20261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty