Healthcare Provider Details

I. General information

NPI: 1164836714
Provider Name (Legal Business Name): BLUE SKY HOLDING'S INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 ATWATER AVE
MANCHESTER MA
01944-1287
US

IV. Provider business mailing address

8 ATWATER AVE
MANCHESTER MA
01944-1287
US

V. Phone/Fax

Practice location:
  • Phone: 978-526-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3439
License Number StateMA

VIII. Authorized Official

Name: JOHN DONOVAN
Title or Position: OWNER
Credential:
Phone: 978-526-8900