Basic Information
| Provider Information | |||||||||
| NPI: | 1275532426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE OF RALEIGH LLC | ||||||||
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| OtherOrganizationName: | BLUE RIDGE HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3830 BLUE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276124319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197814900 | ||||||||
| FaxNumber: | 9195712583 | ||||||||
| Practice Location | |||||||||
| Address1: | 3830 BLUE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276124319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197814900 | ||||||||
| FaxNumber: | 9195712583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 02/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRESLIN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP | ||||||||
| AuthorizedOfficialTelephone: | 2012424004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 340613WW | 05 | NC | MEDICAID |