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General NPI Number Information
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NPI Number | 1891496667
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Entity Type | Organization
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Legal Business Name | INDIBLU MANAGEMENT LLC
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Dates
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Enumeration Date | 03/16/2023
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Last Update Date | 03/16/2023
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Provider Practice Location Address
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Address Line | 1425 SW 110TH WAY
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City | DAVIE
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State | FL
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Zip | 33324-7185
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Country | US
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Telephone | 954-445-9806
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Fax | 954-337-8265
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Provider Business Mailing Address
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Address Line | 1425 SW 110TH WAY
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City | DAVIE
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State | FL
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Zip | 33324-7185
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Country | US
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Telephone | 954-445-9806
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Fax | 954-337-8265
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | LUCINDA BLUNT
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Credential |
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Telephone | 754-224-9333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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