Healthcare Provider Details

I. General information

NPI: 1366996647
Provider Name (Legal Business Name): MY BLUEBONNET COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13359 N HIGHWAY 183 STE403
AUSTIN TX
78750-7153
US

IV. Provider business mailing address

13359 N HIGHWAY 183 STE403
AUSTIN TX
78750-7153
US

V. Phone/Fax

Practice location:
  • Phone: 512-867-6200
  • Fax: 512-519-1127
Mailing address:
  • Phone: 512-867-6200
  • Fax: 512-519-1127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: QING LIU
Title or Position: BUSINESS DEVELOPMENT MANAGER
Credential:
Phone: 512-867-6200