MEDICARE: BLUES BUSTERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1275914707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUES BUSTERS

Provider Business Mailing Address
First Line	:	PO BOX 148
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-0148
Country	:	US
Telephone Number	:	269-208-6125
Fax Number	:	269-593-6012

Provider Business Practice Location Address
First Line	:	9572 RED BUD TRL
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-9517
Country	:	US
Telephone Number	:	269-208-6125
Fax Number	:	269-593-6012

Authorized Official
Title or Position	:	CEO
Name	:	ANNA-MAGDALENA L CHRISTIANSON
Credential	:
Telephone Number	:	269-208-6125

Provider Enumeration Date	:	06/10/2015
Last Update Date	:	06/10/2015

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Directions to “BLUES BUSTERS ” Practice Location

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