Provider Demographics
NPI:1164795456
Name:BLUE SKY MINING COMPANY LLC
Entity Type:Organization
Organization Name:BLUE SKY MINING COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-716-2786
Mailing Address - Street 1:811 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-7009
Mailing Address - Country:US
Mailing Address - Phone:941-480-0300
Mailing Address - Fax:941-485-8090
Practice Address - Street 1:811 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-7009
Practice Address - Country:US
Practice Address - Phone:941-480-0300
Practice Address - Fax:941-485-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO 4976156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4755340001Medicare NSC