Healthcare Provider Details

I. General information

NPI: 1083192595
Provider Name (Legal Business Name): BLUE RIDGE INTEGRATIVE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 DRYDEN LOOP
DRYDEN VA
24243
US

IV. Provider business mailing address

189 DINSMORE RD
DRYDEN VA
24243-8378
US

V. Phone/Fax

Practice location:
  • Phone: 252-832-1588
  • Fax: 276-246-1658
Mailing address:
  • Phone: 276-832-1588
  • Fax: 276-246-1658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RODNEY TERRY
Title or Position: PROJECT DIRECTOR
Credential:
Phone: 252-452-6075