Provider Demographics
NPI:1427670975
Name:BLUE SKY VITAMIN LLC
Entity type:Organization
Organization Name:BLUE SKY VITAMIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DENIS
Authorized Official - Last Name:LEDOUX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-270-5011
Mailing Address - Street 1:160 83RD AVE NE STE 106
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1846
Mailing Address - Country:US
Mailing Address - Phone:800-743-1406
Mailing Address - Fax:
Practice Address - Street 1:160 83RD AVE NE STE 106
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1846
Practice Address - Country:US
Practice Address - Phone:800-743-1406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service