=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497471478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE AUTISM SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 836 PECAN TREE LN
-----------------------------------------------------
City | FORT MILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29715-7010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-439-1032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 836 PECAN TREE LN
-----------------------------------------------------
City | FORT MILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29715-7010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-439-1032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER FOUNDER
-----------------------------------------------------
Name | MR. VIVEK R SAMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-439-1032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------