Provider Demographics
NPI:1851844815
Name:BLUE AUTUMN BALANCE, LLC
Entity Type:Organization
Organization Name:BLUE AUTUMN BALANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:KI
Authorized Official - Last Name:HACELY
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:503-583-3235
Mailing Address - Street 1:2850 SW CEDAR HILLS BLVD
Mailing Address - Street 2:#254
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1354
Mailing Address - Country:US
Mailing Address - Phone:503-583-3235
Mailing Address - Fax:
Practice Address - Street 1:10200 SW EASTRIDGE ST
Practice Address - Street 2:#135
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5064
Practice Address - Country:US
Practice Address - Phone:503-583-3235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1279175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty