Healthcare Provider Details

I. General information

NPI: 1447191705
Provider Name (Legal Business Name): CHIC AESTHETICS AND WELLNESS X MICHAELA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 GHOLSTON AVE
CLINTON OK
73601-5105
US

IV. Provider business mailing address

1421 GHOLSTON AVE
CLINTON OK
73601-5105
US

V. Phone/Fax

Practice location:
  • Phone: 580-309-1990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER M RODRIGUEZ
Title or Position: OWNER
Credential:
Phone: 580-309-1990