Provider Demographics
NPI:1346495512
Name:BIOBLU, LLC
Entity Type:Organization
Organization Name:BIOBLU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVISORY PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:866-288-3822
Mailing Address - Street 1:9229 S 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-2133
Mailing Address - Country:US
Mailing Address - Phone:866-288-3822
Mailing Address - Fax:
Practice Address - Street 1:9229 S 78TH AVE
Practice Address - Street 2:
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-2133
Practice Address - Country:US
Practice Address - Phone:866-288-3822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011278111N00000X, 111NN0400X, 111NN1001X, 111NT0100X
IL038011143111NN0400X, 111NT0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No111NT0100XChiropractic ProvidersChiropractorThermographyGroup - Multi-Specialty