Healthcare Provider Details

I. General information

NPI: 1043600711
Provider Name (Legal Business Name): BLUE RIDGE IN GEORGETOWN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 S ISLAND RD
GEORGETOWN SC
29440-4415
US

IV. Provider business mailing address

2715 S ISLAND RD
GEORGETOWN SC
29440-4415
US

V. Phone/Fax

Practice location:
  • Phone: 843-526-4123
  • Fax: 843-527-4465
Mailing address:
  • Phone: 843-526-4123
  • Fax: 843-527-4465

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: FACILITY ADMINISTRATOR
Title or Position: ADMINISTRATOR
Credential:
Phone: 843-546-4123