Basic Information
| Provider Information | |||||||||
| NPI: | 1104081819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE WATER EYE CARE ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2609 ELECTRIC AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109821300 | ||||||||
| FaxNumber: | 8109829802 | ||||||||
| Practice Location | |||||||||
| Address1: | 2609 ELECTRIC AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109821300 | ||||||||
| FaxNumber: | 8109829802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROCHU | ||||||||
| AuthorizedOfficialFirstName: | KATY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING | ||||||||
| AuthorizedOfficialTelephone: | 8109821300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.