Provider Demographics
NPI:1134900798
Name:HYDRATONIC MED SPA, LLC
Entity type:Organization
Organization Name:HYDRATONIC MED SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN-C/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:863-254-7363
Mailing Address - Street 1:PO BOX 824
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-0824
Mailing Address - Country:US
Mailing Address - Phone:863-254-7363
Mailing Address - Fax:
Practice Address - Street 1:1012 MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-5511
Practice Address - Country:US
Practice Address - Phone:863-254-7363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care