Provider Demographics
NPI:1891991543
Name:BLUE WHALE, INC.
Entity Type:Organization
Organization Name:BLUE WHALE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:MUNCEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:505-898-7760
Mailing Address - Street 1:10028 COORS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4393
Mailing Address - Country:US
Mailing Address - Phone:505-898-7760
Mailing Address - Fax:505-890-9339
Practice Address - Street 1:10028 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4393
Practice Address - Country:US
Practice Address - Phone:505-898-7760
Practice Address - Fax:505-890-9339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2427152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty