Provider Demographics
NPI:1689857831
Name:BLUE HERON HEALTH CENTERS
Entity type:Organization
Organization Name:BLUE HERON HEALTH CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-234-2886
Mailing Address - Street 1:2143 GILMER RD.
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604
Mailing Address - Country:US
Mailing Address - Phone:903-234-2886
Mailing Address - Fax:903-234-2451
Practice Address - Street 1:2143 GILMER RD.
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604
Practice Address - Country:US
Practice Address - Phone:903-234-2886
Practice Address - Fax:903-234-2451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
TX10319111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty