Provider Demographics
NPI:1962192922
Name:BLUESTONE CLINIC LLC
Entity type:Organization
Organization Name:BLUESTONE CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-577-2266
Mailing Address - Street 1:800 NW POWHATAN TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2733
Mailing Address - Country:US
Mailing Address - Phone:260-577-2266
Mailing Address - Fax:
Practice Address - Street 1:111 SW 5TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3604
Practice Address - Country:US
Practice Address - Phone:260-577-2266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty