Basic Information
| Provider Information | |||||||||
| NPI: | 1053060475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE WAVE EYE DOCTORS PROFESSIONAL LIMITED LIABILITY COMPANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782052299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7264444078 | ||||||||
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| Practice Location | |||||||||
| Address1: | 305 SE EVERETT MALL WAY STE 21 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982083250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253868428 | ||||||||
| FaxNumber: | 4252670575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2022 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | HANSRA | ||||||||
| AuthorizedOfficialFirstName: | GULROOP | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7264444078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.