1679177893 NPI number — BLUE RIDGE EYE ASSOCIATES OF ROCKBRIDGE COUNTY LLC

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 1679177893 NPI number — BLUE RIDGE EYE ASSOCIATES OF ROCKBRIDGE COUNTY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE EYE ASSOCIATES OF ROCKBRIDGE COUNTY 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:
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:
1679177893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 CROSSING LN STE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24450-6354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-275-9404
Provider Business Mailing Address Fax Number:
540-463-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 CROSSING LN STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24450-6354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-275-9404
Provider Business Practice Location Address Fax Number:
540-463-1722
Provider Enumeration Date:
11/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PETRIE
Authorized Official First Name:
LINDSAY
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER/OPTOMETRIST
Authorized Official Telephone Number:
847-275-9404

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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