Healthcare Provider Details

I. General information

NPI: 1730610981
Provider Name (Legal Business Name): BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7021 W LEE HWY STE C2
RURAL RETREAT VA
24368-2933
US

IV. Provider business mailing address

7021 W LEE HWY STE C2
RURAL RETREAT VA
24368-2933
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-3740
  • Fax: 276-258-3745
Mailing address:
  • Phone: 276-258-3740
  • Fax: 276-258-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. CARL STEVEN KILGORE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 423-915-5185