Provider Demographics
NPI:1396379780
Name:BLUE WATER HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:BLUE WATER HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:SECUNDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-595-2583
Mailing Address - Street 1:340 TOWN PLACE AVE. SUITE 240
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081
Mailing Address - Country:US
Mailing Address - Phone:904-595-2583
Mailing Address - Fax:904-595-2584
Practice Address - Street 1:340 TOWN PLACE AVE. SUITE 240
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081
Practice Address - Country:US
Practice Address - Phone:904-595-2583
Practice Address - Fax:904-595-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty