=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205215001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 PROFESSIONAL PARK DR SE SUITE 6
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-6735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-552-4588
-----------------------------------------------------
Fax | 540-552-4612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 PROFESSIONAL PARK DR SE SUITE 6
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-6735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-552-4588
-----------------------------------------------------
Fax | 540-552-4612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/ CORPORATE SECRETARY
-----------------------------------------------------
Name | CHRISTOPHER M CLARK
-----------------------------------------------------
Credential | LICENSED OPTICIAN
-----------------------------------------------------
Telephone | 540-776-9722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 11011002026
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------