Provider Demographics
NPI:1962199414
Name:BLUE WATER HOME CARE
Entity type:Organization
Organization Name:BLUE WATER HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PEASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-385-4275
Mailing Address - Street 1:4128 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1520
Mailing Address - Country:US
Mailing Address - Phone:215-385-4275
Mailing Address - Fax:
Practice Address - Street 1:111 CARLTON PL
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2105
Practice Address - Country:US
Practice Address - Phone:215-385-4275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care