Provider Demographics
NPI:1326477928
Name:BLUE WATER DEVELOPMENTAL HOUSING
Entity Type:Organization
Organization Name:BLUE WATER DEVELOPMENTAL HOUSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPPORT WORKER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KILBOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-388-1200
Mailing Address - Street 1:1600 GRATIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1145
Mailing Address - Country:US
Mailing Address - Phone:810-388-1200
Mailing Address - Fax:
Practice Address - Street 1:1600 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1145
Practice Address - Country:US
Practice Address - Phone:810-388-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care