Provider Demographics
NPI:1083625867
Name:BLUE HERON CENTER INCORPORATED
Entity Type:Organization
Organization Name:BLUE HERON CENTER INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBATCH
Authorized Official - Suffix:
Authorized Official - Credentials:OMD
Authorized Official - Phone:512-266-2059
Mailing Address - Street 1:PO BOX 340266
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734-0005
Mailing Address - Country:US
Mailing Address - Phone:512-266-2059
Mailing Address - Fax:
Practice Address - Street 1:15204 GEBRON DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78734-6306
Practice Address - Country:US
Practice Address - Phone:512-266-2059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00271171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty