Provider Demographics
NPI:1386408706
Name:BLUEROCK MEDICAL LLC
Entity type:Organization
Organization Name:BLUEROCK MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:LECLAIR
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:863-873-0072
Mailing Address - Street 1:505 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-2341
Mailing Address - Country:US
Mailing Address - Phone:863-873-0072
Mailing Address - Fax:
Practice Address - Street 1:810 N RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-7217
Practice Address - Country:US
Practice Address - Phone:863-873-0072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-07
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1164189015OtherNPI