Organization
BLUE WATER THERAPY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GABRIEL THOMAS EVENSON MOTR/L (PRESIDENT)
(701) 200-8181
Entity
Organization
Contact information
Practice address
3321 4TH AVE S STE D, FARGO, ND 58103-2235
(701) 200-8181
Mailing address
4425 47TH ST S, FARGO, ND 58104-4201
(701) 200-8181
Taxonomy
Speciality
Code
Description
License number
State
261QR0400X
Rehabilitation Clinic/Center
Primary
995
ND
Other
Enumeration date
12/12/2008
Last updated
12/12/2008
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