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General NPI Number Information
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NPI Number | 1811412091
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Entity Type | Organization
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Legal Business Name | H2O:HEALTH HYDRATION OASIS
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Dates
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Enumeration Date | 08/08/2017
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Last Update Date | 08/08/2017
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Provider Practice Location Address
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Address Line | 17110 W GREENFIELD AVE STE 6
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City | BROOKFIELD
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State | WI
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Zip | 53005-6899
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Country | US
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Telephone | 269-998-0683
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Fax |
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Provider Business Mailing Address
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Address Line | 13130 WATERTOWN PLANK RD UNIT 201
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City | ELM GROVE
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State | WI
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Zip | 53122-2240
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Country | US
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Telephone | 269-998-0683
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Fax |
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Authorized Official
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Title or Position | FOUNDER, MEDICAL DIRECTOR
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Name | DR. ALIA LYNELL FOX
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Credential | MD
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Telephone | 269-998-0683
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 55919-20
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License Number State | WI
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