MEDICARE: BLUE RIVER HEALTH SYSTEM, LLC

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	253Z00000X	In Home Supportive Care Agency
2	3747P1801X	Personal Care Attendant	016527	TX

General Provider Information

NPI Number	:	1780096685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE RIVER HEALTH SYSTEM, LLC

Provider Business Mailing Address
First Line	:	1128 BANDERA RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-4023
Country	:	US
Telephone Number	:	210-530-4788
Fax Number	:	210-281-4028

Provider Business Practice Location Address
First Line	:	1128 BANDERA RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-4023
Country	:	US
Telephone Number	:	210-530-4788
Fax Number	:	210-281-4028

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	LORENA ROIG
Credential	:
Telephone Number	:	210-530-4788

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	05/13/2022

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