Basic Information
| Provider Information | |||||||||
| NPI: | 1770973455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE RIDGE OF SUMTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUE RIDGE OF SUMTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1761 PINEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291549056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034818591 | ||||||||
| FaxNumber: | 8034818601 | ||||||||
| Practice Location | |||||||||
| Address1: | 1761 PINEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291549056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034818591 | ||||||||
| FaxNumber: | 8034818601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialFirstName: | FACILITY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8034818591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.