Basic Information
| Provider Information | |||||||||
| NPI: | 1689114761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESSENCE PREMIER HEALTH, LLC | ||||||||
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| OtherOrganizationName: | BLUE RIDGE CHRONIC PAIN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 16830 FOREST RD | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245514059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345152775 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2017 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | DON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4349428417 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 0101230590 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.