MEDICARE: THE HYDRATION ROOM

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	:	1376234500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HYDRATION ROOM

Provider Business Mailing Address
First Line	:	833 ANDERSON AVE STE 1
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-4641
Country	:	US
Telephone Number	:	541-290-3090
Fax Number	:

Provider Business Practice Location Address
First Line	:	833 ANDERSON AVE STE 1
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-4641
Country	:	US
Telephone Number	:	541-290-3090
Fax Number	:

Authorized Official
Title or Position	:	FNP/OWNER
Name	:	MS. NIKKONA HENDERSON
Credential	:	FNP
Telephone Number	:	541-290-3090

Provider Enumeration Date	:	05/18/2023
Last Update Date	:	06/01/2023

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Directions to “THE HYDRATION ROOM ” Practice Location

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