MEDICARE: BLUE RIVER COMMERCIAL INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1295597193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIVER COMMERCIAL INC

Provider Business Mailing Address
First Line	:	1400 NE MIAMI GARDENS DR STE 206B
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-4840
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 NE MIAMI GARDENS DR STE 206B
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-4840
Country	:	US
Telephone Number	:	305-627-3161
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	YASIEL MORELL MANZARRAGA
Credential	:
Telephone Number	:	305-627-3161

Provider Enumeration Date	:	01/25/2024
Last Update Date	:	05/28/2025

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