Provider Demographics
NPI:1477050375
Name:BLUE YE MAYA LLC
Entity Type:Organization
Organization Name:BLUE YE MAYA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-246-4466
Mailing Address - Street 1:531 E LYNWOOD ST FL 2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:531 E LYNWOOD ST FL 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1626
Practice Address - Country:US
Practice Address - Phone:602-821-1594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty