Provider Demographics
NPI:1417774597
Name:BLUE CLINICAL CENTER LLC
Entity type:Organization
Organization Name:BLUE CLINICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CODECIDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-663-2822
Mailing Address - Street 1:6300 CORPORATE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6300 CORPORATE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3513
Practice Address - Country:US
Practice Address - Phone:786-803-8517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)