1396706065 NPI number — BLUE RIDGE THERAPY ASSOCIATES, INC.

Table of content: (NPI 1396706065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396706065 NPI number — BLUE RIDGE THERAPY ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE THERAPY ASSOCIATES, INC.
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:
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:
1396706065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1912 MEMORIAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24501-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-845-8765
Provider Business Mailing Address Fax Number:
434-845-8467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1912 MEMORIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNCHBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24501-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-845-8765
Provider Business Practice Location Address Fax Number:
434-845-8467
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHROCK
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
434-845-8765

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004978757 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 192595 . This is a "ANTHEM PT" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 192597 . This is a "ANTHEM ST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: QPA413 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 192596 . This is a "ANTHEM OT" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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