Provider Demographics
NPI:1023743283
Name:BLUE WAVE EYE DOCTORS PROFESSIONAL LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:BLUE WAVE EYE DOCTORS PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOLSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:726-444-4078
Mailing Address - Street 1:175 E HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-2299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 S STEELE ST UNIT A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7317
Practice Address - Country:US
Practice Address - Phone:253-317-2704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-21
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier