Healthcare Provider Details

I. General information

NPI: 1124612049
Provider Name (Legal Business Name): BLUE PEARL YOGA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 02/22/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E MAIN ST
BATAVIA NY
14020-2200
US

IV. Provider business mailing address

200 E MAIN ST
BATAVIA NY
14020-2200
US

V. Phone/Fax

Practice location:
  • Phone: 585-201-7310
  • Fax:
Mailing address:
  • Phone: 585-201-7310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAREN REISDORF
Title or Position: ADMIN
Credential:
Phone: 301-848-4902