Healthcare Provider Details

I. General information

NPI: 1053022871
Provider Name (Legal Business Name): BLUE WAVE EYE DOCTORS, PROFESSIONAL LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 04/07/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NE NORTHGATE WAY
SEATTLE WA
98125
US

IV. Provider business mailing address

175 E HOUSTON ST
SAN ANTONIO TX
78205-2299
US

V. Phone/Fax

Practice location:
  • Phone: 206-210-5963
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DOLSIE MCDONALD
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 726-444-4078