Provider Demographics
NPI:1063656791
Name:SPA BLU
Entity Type:Organization
Organization Name:SPA BLU
Other - Org Name:SPA BLU, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/LMT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUMBLETON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:850-231-5784
Mailing Address - Street 1:57 A UPTOWN GRAYTON CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GRAYTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459
Mailing Address - Country:US
Mailing Address - Phone:850-231-5784
Mailing Address - Fax:850-231-4718
Practice Address - Street 1:57 UPTOWN GRAYTON CIR STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-8814
Practice Address - Country:US
Practice Address - Phone:850-231-5784
Practice Address - Fax:850-231-4718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM16325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty