Healthcare Provider Details

I. General information

NPI: 1962621888
Provider Name (Legal Business Name): BLUE MOUNTAIN ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 I AVE
LA GRANDE OR
97850
US

IV. Provider business mailing address

PO BOX 1005
LA GRANDE OR
97850
US

V. Phone/Fax

Practice location:
  • Phone: 541-962-0162
  • Fax: 541-962-0119
Mailing address:
  • Phone: 541-962-0162
  • Fax: 541-962-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MEGGEN M BROGOITTI
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-962-0162