Provider Demographics
NPI:1487130605
Name:BLUE HERON HEALTH LLC
Entity type:Organization
Organization Name:BLUE HERON HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:203-873-8050
Mailing Address - Street 1:220 MAIN ST S STE 205
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2275
Mailing Address - Country:US
Mailing Address - Phone:203-814-1455
Mailing Address - Fax:203-264-2208
Practice Address - Street 1:82A MEADOW ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3543
Practice Address - Country:US
Practice Address - Phone:203-814-1455
Practice Address - Fax:203-264-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000376261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service