Provider Demographics
NPI:1720809767
Name:BLUE RIVER HEALTH SERVICES, PLLC
Entity type:Organization
Organization Name:BLUE RIVER HEALTH SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HICKLEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:919-234-7798
Mailing Address - Street 1:5540 CENTERVIEW DR
Mailing Address - Street 2:STE 204 PMB 777298
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2715 CHERT LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-7189
Practice Address - Country:US
Practice Address - Phone:919-234-7798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801596572OtherINDIVIDUAL NPI