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General NPI Number Information
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NPI Number | 1740969252
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Entity Type | Organization
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Legal Business Name | BLUEWATER INFUSION CLINIC INC.
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Dates
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Enumeration Date | 07/12/2023
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Last Update Date | 08/15/2023
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Provider Practice Location Address
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Address Line | 921 MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6653
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Country | US
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Telephone | 850-388-4333
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Fax | 850-388-4338
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Provider Business Mailing Address
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Address Line | 921 MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6653
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Country | US
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Telephone | 850-388-4333
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Fax | 850-388-4338
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Authorized Official
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Title or Position | OWNER
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Name | TIMOTHY MIXON
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Credential |
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Telephone | 251-923-5537
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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