Healthcare Provider Details

I. General information

NPI: 1598130544
Provider Name (Legal Business Name): BLUE RIDGE IN BROOKVIEW HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 THOMPSON ST
GAFFNEY SC
29340-3620
US

IV. Provider business mailing address

2700 N 29TH AVE SUITE 308
HOLLYWOOD FL
33020-1520
US

V. Phone/Fax

Practice location:
  • Phone: 864-489-3101
  • Fax: 864-489-4888
Mailing address:
  • Phone: 786-358-5200
  • Fax: 786-664-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LEVI RUDD
Title or Position: CEO
Credential:
Phone: 786-358-5200