Provider Demographics
NPI:1508323684
Name:BLUE HORIZON PROFESSIONAL GROUP, INC
Entity Type:Organization
Organization Name:BLUE HORIZON PROFESSIONAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-288-6046
Mailing Address - Street 1:1591 HAYLEY LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-2121
Mailing Address - Country:US
Mailing Address - Phone:239-288-6046
Mailing Address - Fax:888-388-5055
Practice Address - Street 1:1591 HAYLEY LN STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2121
Practice Address - Country:US
Practice Address - Phone:239-288-6046
Practice Address - Fax:888-388-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1568930915Medicaid