MEDICARE: BLUE HERON RECOVERY LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1861098188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE HERON RECOVERY LLC

Provider Business Mailing Address
First Line	:	2015 NE LOOP 410
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-5411
Country	:	US
Telephone Number	:	210-291-6426
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 NE LOOP 410
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-5411
Country	:	US
Telephone Number	:	210-291-6426
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTINE M VARELA MAYER
Credential	:	PHD
Telephone Number	:	210-291-6426

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	12/10/2020

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