Provider Demographics
NPI:1619462272
Name:BLUE SEAS MEDICAL LLC
Entity Type:Organization
Organization Name:BLUE SEAS MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-247-7389
Mailing Address - Street 1:PO BOX 2998
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-2998
Mailing Address - Country:US
Mailing Address - Phone:772-247-7389
Mailing Address - Fax:
Practice Address - Street 1:5850 SE COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6420
Practice Address - Country:US
Practice Address - Phone:772-247-7389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9508207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty