Provider Demographics
NPI:1881313047
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:
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:800-340-0129
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:921 N 10TH ST STE B
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5591
Practice Address - Country:US
Practice Address - Phone:425-255-1022
Practice Address - Fax:425-255-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier