Provider Demographics
NPI:1275072472
Name:BLUE NILE PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:BLUE NILE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-552-0657
Mailing Address - Street 1:195 INVERNESS DR W
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-5206
Mailing Address - Country:US
Mailing Address - Phone:303-552-0657
Mailing Address - Fax:
Practice Address - Street 1:11275 E MISSISSIPPI AVE STE 2W2
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3263
Practice Address - Country:US
Practice Address - Phone:303-856-7177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0046896261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care