Healthcare Provider Details

I. General information

NPI: 1528882453
Provider Name (Legal Business Name): BLUE ICEBERG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 W CROSS DR UNIT B1
LITTLETON CO
80123-2200
US

IV. Provider business mailing address

8156 S WADSWORTH BLVD UNIT E-459
LITTLETON CO
80128-9114
US

V. Phone/Fax

Practice location:
  • Phone: 651-214-0197
  • Fax:
Mailing address:
  • Phone: 651-214-0197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVE YANG
Title or Position: CEO
Credential:
Phone: 651-214-0197