Provider Demographics
NPI:1093140618
Name:BLUEWATER TOXICOLOGY LLC
Entity Type:Organization
Organization Name:BLUEWATER TOXICOLOGY LLC
Other - Org Name:BLUEWATER TOXICOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOLUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-538-2980
Mailing Address - Street 1:221 S BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-7248
Mailing Address - Country:US
Mailing Address - Phone:502-538-2980
Mailing Address - Fax:502-538-0352
Practice Address - Street 1:221 S BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7248
Practice Address - Country:US
Practice Address - Phone:502-538-2980
Practice Address - Fax:502-538-0352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18D2063609291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0156117Medicaid
KY7100337990Medicaid
TNQ045535Medicaid
KY18D2063609OtherCLIA # 18D2063609
KY200358OtherCOMMONWEALTH OF KENTUCKY MEDICAL LABORATORY
KY24777OtherCOLA #