Healthcare Provider Details

I. General information

NPI: 1134730864
Provider Name (Legal Business Name): BLUEH IV HEALTH SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9625 DAVID TAYLOR DR
CHARLOTTE NC
28262-2362
US

IV. Provider business mailing address

3208 GRANDEUR RD
CHARLOTTE NC
28269-3217
US

V. Phone/Fax

Practice location:
  • Phone: 704-942-8281
  • Fax: 352-554-5073
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LA TOYA DAWSON
Title or Position: BILLING DIRECTOR
Credential:
Phone: 352-231-7551