Healthcare Provider Details

I. General information

NPI: 1932876018
Provider Name (Legal Business Name): BLUEBONNET LIFECARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/17/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 ASHLAND WOODS DR
SPRING TX
77386-4381
US

IV. Provider business mailing address

4015 ASHLAND WOODS DR
SPRING TX
77386-4381
US

V. Phone/Fax

Practice location:
  • Phone: 832-433-0465
  • Fax:
Mailing address:
  • Phone: 832-433-0465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: EMEM EPHRAIM UDOH
Title or Position: ADMINISTRATOR/MANAGING MEMBER
Credential:
Phone: 832-433-0465