MEDICARE: HYDROGLO AESTETICS AND WELLNESS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261Q00000X	Clinic/Center
2	261QI0500X	Infusion Therapy Clinic/Center
3	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1225757255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYDROGLO AESTETICS AND WELLNESS

Provider Business Mailing Address
First Line	:	2237 W MEMORIAL RD STE 112
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-8064
Country	:	US
Telephone Number	:	405-849-4785
Fax Number	:	405-286-1698

Provider Business Practice Location Address
First Line	:	2237 W MEMORIAL RD STE 112
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-8064
Country	:	US
Telephone Number	:	405-849-4785
Fax Number	:	405-286-1698

Authorized Official
Title or Position	:	MANAGER
Name	:	JILLIAN HERNDON
Credential	:
Telephone Number	:	405-557-1200

Provider Enumeration Date	:	08/23/2022
Last Update Date	:	09/10/2024

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Directions to “HYDROGLO AESTETICS AND WELLNESS ” Practice Location

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