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General NPI Number Information
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NPI Number | 1164394177
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE INTEGRATIVE WELLNESS LLC
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Dates
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Enumeration Date | 09/19/2025
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Last Update Date | 10/03/2025
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Provider Practice Location Address
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Address Line | 512 DRYDEN LOOP
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City | DRYDEN
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State | VA
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Zip | 24243
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Country | US
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Telephone | 941-391-7261
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Fax |
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Provider Business Mailing Address
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Address Line | 512 DRYDEN LOOP
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City | DRYDEN
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State | VA
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Zip | 24243
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Country | US
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Telephone | 941-391-7261
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, CFO
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Name | TRACY ROGERS
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Credential | LMHC, LPC
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Telephone | 941-391-7261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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