Provider Demographics
NPI:1518857416
Name:BLUE HORIZEN WELLNESS
Entity type:Organization
Organization Name:BLUE HORIZEN WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHITTU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-266-3404
Mailing Address - Street 1:3173 W RIVER ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2217
Mailing Address - Country:US
Mailing Address - Phone:909-266-3404
Mailing Address - Fax:909-266-3404
Practice Address - Street 1:3333 S SUNNY SLOPE RD STE 108
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4504
Practice Address - Country:US
Practice Address - Phone:262-317-9660
Practice Address - Fax:262-317-9660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty