Basic Information
| Provider Information | |||||||||
| NPI: | 1265435333 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE RIDGE NURSING CENTER OF MARTINSVILLE AND HENRY COUNTY INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUE RIDGE REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3073 HORSESHOE DR S | ||||||||
| Address2: | STE 102 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341046144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399633400 | ||||||||
| FaxNumber: | 2399633401 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BLUE RIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241127261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766388701 | ||||||||
| FaxNumber: | 2766382017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 12/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | DORENE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MIS | ||||||||
| AuthorizedOfficialTelephone: | 2399633400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2510 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4952812 | 05 | VA | MEDICAID |