Healthcare Provider Details

I. General information

NPI: 1679490155
Provider Name (Legal Business Name): BLUESTONE HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 VINE ST STE 206C
LOS ANGELES CA
90028-5250
US

IV. Provider business mailing address

1800 VINE ST STE 206C
LOS ANGELES CA
90028-5250
US

V. Phone/Fax

Practice location:
  • Phone: 310-863-0015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EGOR PETROV
Title or Position: CEO
Credential:
Phone: 310-863-0015