MEDICARE: RIVER OAKS AESTHETIC & WELLNESS SPA, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QI0500X	Infusion Therapy Clinic/Center

General Provider Information

NPI Number	:	1164160404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER OAKS AESTHETIC & WELLNESS SPA, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2269
Second Line	:
City	:	STAFFORD
State	:	TX
Zip	:	77497-2269
Country	:	US
Telephone Number	:	713-408-0672
Fax Number	:

Provider Business Practice Location Address
First Line	:	2111 WEST LOOP SOUTH
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77027
Country	:	US
Telephone Number	:	713-408-0672
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	AGNES USORO
Credential	:	MD
Telephone Number	:	832-466-9714

Provider Enumeration Date	:	05/26/2022
Last Update Date	:	05/26/2022

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