1114411329 NPI number — BLUE RIDGE CARE SOLUTIONS, LLC.

Table of content: (NPI 1114411329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114411329 NPI number — BLUE RIDGE CARE SOLUTIONS, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE CARE SOLUTIONS, LLC.
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:
Provider Other Organization Name Type Code:
6
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:
1114411329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37602-6175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-900-8499
Provider Business Mailing Address Fax Number:
866-404-0950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 MED TECH PKWY STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-2643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-900-8499
Provider Business Practice Location Address Fax Number:
866-404-0950
Provider Enumeration Date:
06/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
HANNAH
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
423-900-8499

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  I000000021323 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L000000027512 . This is a "PSSA LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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