Provider Demographics
NPI:1992046668
Name:MY BLUE SKY PC
Entity type:Organization
Organization Name:MY BLUE SKY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:ROZIER
Authorized Official - Last Name:AUTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-257-2005
Mailing Address - Street 1:3419B MELROSE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1608
Mailing Address - Country:US
Mailing Address - Phone:910-257-2005
Mailing Address - Fax:910-485-6315
Practice Address - Street 1:3419B MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1608
Practice Address - Country:US
Practice Address - Phone:910-257-2005
Practice Address - Fax:910-485-6315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6074252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency