Provider Demographics
NPI:1396072344
Name:BIG BLUE STAR LLC
Entity type:Organization
Organization Name:BIG BLUE STAR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOBY
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-974-8412
Mailing Address - Street 1:1800 RENAISSANCE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3023
Mailing Address - Country:US
Mailing Address - Phone:404-359-2473
Mailing Address - Fax:
Practice Address - Street 1:1800 RENAISSANCE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3023
Practice Address - Country:US
Practice Address - Phone:404-359-2473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty