Basic Information
| Provider Information | |||||||||
| NPI: | 1881313047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 8003400129 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 N 10TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980575591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252551022 | ||||||||
| FaxNumber: | 4252551176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2022 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | DOLSIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7264444078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.