Provider Demographics
NPI:1275046062
Name:BLUE HERON CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:BLUE HERON CHIROPRACTIC, LLC
Other - Org Name:BLUE HERON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-616-2440
Mailing Address - Street 1:19308 76TH AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-6201
Mailing Address - Country:US
Mailing Address - Phone:425-750-6568
Mailing Address - Fax:
Practice Address - Street 1:716 3RD ST UNIT B
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-1548
Practice Address - Country:US
Practice Address - Phone:425-616-2440
Practice Address - Fax:425-332-7078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60517781261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service