Basic Information
Provider Information | |||||||||
NPI: | 1093175549 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLUE RIDGE SENIOR HOUSING, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3715 NORTHSIDE PKWY NW | ||||||||
Address2: | BUILDING 300, SUITE 110 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303272882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042374509 | ||||||||
FaxNumber: | 4042371719 | ||||||||
Practice Location | |||||||||
Address1: | 3715 NORTHSIDE PKWY NW | ||||||||
Address2: | BUILDING 300, SUITE 110 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303272882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042374509 | ||||||||
FaxNumber: | 4042371719 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2016 | ||||||||
LastUpdateDate: | 02/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARPER | ||||||||
AuthorizedOfficialFirstName: | JUDSON | ||||||||
AuthorizedOfficialMiddleName: | IAN | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4042374509 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.