Healthcare Provider Details

I. General information

NPI: 1013478411
Provider Name (Legal Business Name): BLUE RIDGE SNF OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 LANDMARK DR
STUART VA
24171-9401
US

IV. Provider business mailing address

7523 MAIN ST # 39
FLUSHING NY
11367-7652
US

V. Phone/Fax

Practice location:
  • Phone: 276-694-4230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SHIMMY IDELS
Title or Position: COO
Credential:
Phone: 917-565-7391