=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639981566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEEYES SPEECH AND LANGUAGE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2025
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3546 CALLE SUENOS SE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-6716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-530-1737
-----------------------------------------------------
Fax | 505-396-4598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3546 CALLE SUENOS SE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-6716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-530-1737
-----------------------------------------------------
Fax | 505-396-4598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | MRS. JENNIFER HOLLIS GARRISON
-----------------------------------------------------
Credential | SLP
-----------------------------------------------------
Telephone | 913-530-1737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------