Provider Demographics
NPI:1932983301
Name:BLUELIFE WELLNESS, LLC
Entity Type:Organization
Organization Name:BLUELIFE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:DONISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-409-1910
Mailing Address - Street 1:18033 PROMENADE PARK LN APT 203
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-7980
Mailing Address - Country:US
Mailing Address - Phone:813-409-1910
Mailing Address - Fax:
Practice Address - Street 1:18033 PROMENADE PARK LN APT 203
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-7980
Practice Address - Country:US
Practice Address - Phone:813-409-1910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities