Provider Demographics
NPI:1730198805
Name:BLUE WAKE, INC
Entity type:Organization
Organization Name:BLUE WAKE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-264-3153
Mailing Address - Street 1:309 DUNKELD DR
Mailing Address - Street 2:
Mailing Address - City:SPICEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78669-2154
Mailing Address - Country:US
Mailing Address - Phone:512-264-3153
Mailing Address - Fax:512-264-3401
Practice Address - Street 1:309 DUNKELD DR
Practice Address - Street 2:
Practice Address - City:SPICEWOOD
Practice Address - State:TX
Practice Address - Zip Code:78669-2154
Practice Address - Country:US
Practice Address - Phone:512-264-3153
Practice Address - Fax:512-264-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAPPLIED FOR251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health