Provider Demographics
NPI:1295505931
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:MANAGER OF NETWORK MANAGEMENT
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:726-444-4417
Mailing Address - Fax:
Practice Address - Street 1:11066 PACIFIC CREST PL NW STE A140
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6604
Practice Address - Country:US
Practice Address - Phone:360-228-2740
Practice Address - Fax:360-447-6031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-04
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier