Provider Demographics
NPI:1144584038
Name:BLUE LAGOON THERAPY & SERVICES, LLC
Entity Type:Organization
Organization Name:BLUE LAGOON THERAPY & SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:E
Authorized Official - Last Name:NEDERHOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:231-779-4671
Mailing Address - Street 1:2353 S LACHANCE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-8024
Mailing Address - Country:US
Mailing Address - Phone:231-779-4671
Mailing Address - Fax:231-779-4038
Practice Address - Street 1:2353 S LACHANCE RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-8024
Practice Address - Country:US
Practice Address - Phone:231-779-4671
Practice Address - Fax:231-779-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health