Provider Demographics
NPI:1558529560
Name:BLUE HERON CLINIC PC
Entity Type:Organization
Organization Name:BLUE HERON CLINIC PC
Other - Org Name:BLUE HERON CHIROPRACTIC & HEALING ARTS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIBILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-280-9759
Mailing Address - Street 1:1934 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1502
Mailing Address - Country:US
Mailing Address - Phone:503-280-9759
Mailing Address - Fax:503-280-9798
Practice Address - Street 1:1934 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1502
Practice Address - Country:US
Practice Address - Phone:503-280-9759
Practice Address - Fax:503-280-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-2971261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101830Medicare PIN
ORU70851Medicare UPIN