Healthcare Provider Details

I. General information

NPI: 1083456446
Provider Name (Legal Business Name): BLUHAVEN HEALTH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 WAKE FOREST RD STE 220
RALEIGH NC
27609-2510
US

IV. Provider business mailing address

4109 WAKE FOREST RD
RALEIGH NC
27609-2510
US

V. Phone/Fax

Practice location:
  • Phone: 984-370-2350
  • Fax: 984-370-2352
Mailing address:
  • Phone: 984-370-2350
  • Fax: 984-370-2352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHARLIE FRYE
Title or Position: DIRECTOR
Credential:
Phone: 984-370-2350