Provider Demographics
NPI:1245475797
Name:BLUE WATER THERAPY, LLC
Entity type:Organization
Organization Name:BLUE WATER THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:EVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:701-200-8181
Mailing Address - Street 1:4425 47TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4201
Mailing Address - Country:US
Mailing Address - Phone:701-200-8181
Mailing Address - Fax:
Practice Address - Street 1:3321 4TH AVE S STE D
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2235
Practice Address - Country:US
Practice Address - Phone:701-200-8181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND995261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation