MEDICARE: BLUE HERON CENTER INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC00271	TX

General Provider Information

NPI Number	:	1083625867
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE HERON CENTER INCORPORATED

Provider Business Mailing Address
First Line	:	PO BOX 340266
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78734-0005
Country	:	US
Telephone Number	:	512-266-2059
Fax Number	:

Provider Business Practice Location Address
First Line	:	15204 GEBRON DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78734-6306
Country	:	US
Telephone Number	:	512-266-2059
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GAYL HUBATCH
Credential	:	OMD
Telephone Number	:	512-266-2059

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	08/22/2020

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