Provider Demographics
NPI:1881407450
Name:HYDRASPA REJUVENATION STATION LLC
Entity type:Organization
Organization Name:HYDRASPA REJUVENATION STATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:980-310-6381
Mailing Address - Street 1:10301 WINDTREE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-9019
Mailing Address - Country:US
Mailing Address - Phone:980-310-6381
Mailing Address - Fax:
Practice Address - Street 1:11 UNION ST S STE 105
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-5088
Practice Address - Country:US
Practice Address - Phone:980-310-6381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No251F00000XAgenciesHome Infusion
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy