Healthcare Provider Details

I. General information

NPI: 1164394177
Provider Name (Legal Business Name): BLUE RIDGE INTEGRATIVE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2025
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 DRYDEN LOOP
DRYDEN VA
24243
US

IV. Provider business mailing address

512 DRYDEN LOOP
DRYDEN VA
24243
US

V. Phone/Fax

Practice location:
  • Phone: 941-391-7261
  • Fax:
Mailing address:
  • Phone: 941-391-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY ROGERS
Title or Position: PRESIDENT, CFO
Credential: LMHC, LPC
Phone: 941-391-7261