Healthcare Provider Details

I. General information

NPI: 1508669052
Provider Name (Legal Business Name): IMPERIAL BLUE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8296 SEMINOLE TRL
RUCKERSVILLE VA
22968-3492
US

IV. Provider business mailing address

8296 SEMINOLE TRL
RUCKERSVILLE VA
22968-3492
US

V. Phone/Fax

Practice location:
  • Phone: 434-326-7531
  • Fax:
Mailing address:
  • Phone: 434-481-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELSEY MORRIS
Title or Position: OWNER
Credential: FNPC
Phone: 434-326-7531