Provider Demographics
NPI:1053060475
Name:BLUE WAVE EYE DOCTORS PROFESSIONAL LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:BLUE WAVE EYE DOCTORS PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GULROOP
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSRA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:726-444-4078
Mailing Address - Street 1:175 E HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-2299
Mailing Address - Country:US
Mailing Address - Phone:726-444-4078
Mailing Address - Fax:
Practice Address - Street 1:305 SE EVERETT MALL WAY STE 21
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3250
Practice Address - Country:US
Practice Address - Phone:425-386-8428
Practice Address - Fax:425-267-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty