Provider Demographics
NPI:1730450081
Name:GUSTAVOS BLUE SHARK
Entity type:Organization
Organization Name:GUSTAVOS BLUE SHARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-726-0787
Mailing Address - Street 1:7000 DIAMOND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7696
Mailing Address - Country:US
Mailing Address - Phone:915-726-0787
Mailing Address - Fax:915-496-0751
Practice Address - Street 1:7000 DIAMOND RIDGE DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-7696
Practice Address - Country:US
Practice Address - Phone:915-726-0787
Practice Address - Fax:915-496-0751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services