Provider Demographics
NPI:1770231599
Name:AUTHENTIC BLUE LLC
Entity Type:Organization
Organization Name:AUTHENTIC BLUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ODALYS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-339-7500
Mailing Address - Street 1:15282 SW 36TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15282 SW 36TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-4795
Practice Address - Country:US
Practice Address - Phone:786-339-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty