Healthcare Provider Details

I. General information

NPI: 1578865275
Provider Name (Legal Business Name): BLUE STAR HEALING ARTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 NW 5TH ST
GRANTS PASS OR
97526-1529
US

IV. Provider business mailing address

714 NW 5TH ST
GRANTS PASS OR
97526-1529
US

V. Phone/Fax

Practice location:
  • Phone: 541-244-1511
  • Fax: 541-244-1512
Mailing address:
  • Phone: 541-244-1511
  • Fax: 541-244-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMD15235
License Number StateOR

VIII. Authorized Official

Name: MONA MYNNEL TARA
Title or Position: OWNER
Credential: M.D.
Phone: 541-244-2292