Provider Demographics
NPI:1407567290
Name:BLUE WAVE EYE DOCTORS, PROFESSIONAL LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:BLUE WAVE EYE DOCTORS, PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOLSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:726-444-4078
Mailing Address - Street 1:175 E HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-2299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 FACTORIA BLVD SE STE C
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-6113
Practice Address - Country:US
Practice Address - Phone:726-444-4122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-12
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty