Provider Demographics
NPI:1053542977
Name:BLU SPA & SLAON, LLC
Entity type:Organization
Organization Name:BLU SPA & SLAON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEHR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-675-2258
Mailing Address - Street 1:3030 ORCHARD PARK RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-4638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 ORCHARD PARK RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-4638
Practice Address - Country:US
Practice Address - Phone:716-675-2258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21BL1296864174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000500099004OtherBLUECROSS BLUESHIELD OF WESTERN NEW YORK
NY000524717014OtherBLUECROSS BLUESHIELD OF WESTERN NEW YORK