Basic Information
| Provider Information | |||||||||
| NPI: | 1770806291 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUE RIDGE NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 CENTREPARK BLVD STE 810 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334017412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399633400 | ||||||||
| FaxNumber: | 2399633410 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BLUE RIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241127261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766388701 | ||||||||
| FaxNumber: | 2766388843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2010 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | DORENE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF M.I.S. | ||||||||
| 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 | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.