1417355090 NPI number — BLUE RIDGE HEARING GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417355090 NPI number — BLUE RIDGE HEARING GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE HEARING GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MIRACLE EAR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417355090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12925 BOOKER T WASHINGTON HWY
Provider Second Line Business Mailing Address:
STE.202
Provider Business Mailing Address City Name:
HARDY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24101-3971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-444-5659
Provider Business Mailing Address Fax Number:
540-301-1167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12925 BOOKER T WASHINGTON HWY
Provider Second Line Business Practice Location Address:
STE.202
Provider Business Practice Location Address City Name:
HARDY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24101-3971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-444-5659
Provider Business Practice Location Address Fax Number:
540-301-1167
Provider Enumeration Date:
12/12/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
TODD
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
540-444-5659

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  2101001696 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)