Healthcare Provider Details

I. General information

NPI: 1952390221
Provider Name (Legal Business Name): BLUE RIDGE PODIATRY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 S MAIN ST STE 103
ROCKY MOUNT VA
24151-1767
US

IV. Provider business mailing address

PO BOX 4205
EDEN NC
27289-4205
US

V. Phone/Fax

Practice location:
  • Phone: 540-483-7933
  • Fax: 540-463-9454
Mailing address:
  • Phone: 336-623-4545
  • Fax: 206-333-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103000371
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103300877
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103000391
License Number StateVA

VIII. Authorized Official

Name: DR. JOHN LARRY CLEMENTS
Title or Position: PRESIDENT
Credential: D.P.M
Phone: 540-885-8891