Healthcare Provider Details

I. General information

NPI: 1831936962
Provider Name (Legal Business Name): BLUEWATER PRIMARY CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 E HIGHWAY 20 STE 313
NICEVILLE FL
32578-7700
US

IV. Provider business mailing address

4400 E HIGHWAY 20 STE 313
NICEVILLE FL
32578-7700
US

V. Phone/Fax

Practice location:
  • Phone: 850-797-2598
  • Fax:
Mailing address:
  • Phone: 575-520-1230
  • Fax: 773-492-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. LEIGH POWERS
Title or Position: OWNER
Credential: DNP, MSN, PMHNP-BC
Phone: 755-201-2305