Provider Demographics
NPI:1871521450
Name:BLUE WATER PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:BLUE WATER PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VARDHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUDIGONDA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:810-824-2038
Mailing Address - Street 1:3560 PINE GROVE AVE # 614
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1994
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1209 10TH ST STE A
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5262
Practice Address - Country:US
Practice Address - Phone:810-824-2038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P21540Medicare ID - Type Unspecified