Healthcare Provider Details

I. General information

NPI: 1104130376
Provider Name (Legal Business Name): BLUE RIDGE PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457B HIGHWAY 123
SENECA SC
29678-0842
US

IV. Provider business mailing address

457B HIGHWAY 123
SENECA SC
29678-0842
US

V. Phone/Fax

Practice location:
  • Phone: 864-888-4464
  • Fax:
Mailing address:
  • Phone: 864-888-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number261QR1300X
License Number StateSC

VIII. Authorized Official

Name: CAREY MOLIN GULLY
Title or Position: OWNER
Credential: MD
Phone: 864-888-4464