Provider Demographics
NPI:1316008394
Name:BLU BIRD INC
Entity Type:Organization
Organization Name:BLU BIRD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:PETERKIN
Authorized Official - Last Name:CONGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-874-4369
Mailing Address - Street 1:711 HARRY RAYSOR DR
Mailing Address - Street 2:
Mailing Address - City:SAINT MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135
Mailing Address - Country:US
Mailing Address - Phone:803-874-4369
Mailing Address - Fax:803-874-1772
Practice Address - Street 1:711 HARRY RAYSOR DR
Practice Address - Street 2:
Practice Address - City:SAINT MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135
Practice Address - Country:US
Practice Address - Phone:803-874-4369
Practice Address - Fax:803-874-1772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00071953332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1411Medicaid
SCDE1411Medicaid