Provider Demographics
NPI:1134737778
Name:BLUE WATERS WELLNESS LLC
Entity type:Organization
Organization Name:BLUE WATERS WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:912-314-3023
Mailing Address - Street 1:6257 OLD AXSON RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31535-3429
Mailing Address - Country:US
Mailing Address - Phone:912-314-3023
Mailing Address - Fax:
Practice Address - Street 1:403 WARD ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3505
Practice Address - Country:US
Practice Address - Phone:912-260-0005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty