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General NPI Number Information
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NPI Number | 1235724774
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE VISION, INC.
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Dates
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Enumeration Date | 03/06/2021
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Last Update Date | 03/06/2021
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Provider Practice Location Address
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Address Line | 180 TOCCOA CT
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City | ELLIJAY
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State | GA
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Zip | 30540-0604
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Country | US
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Telephone | 770-402-1175
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Fax |
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Provider Business Mailing Address
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Address Line | 180 TOCCOA CT
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City | ELLIJAY
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State | GA
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Zip | 30540-0604
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MICHAEL R DOUCETTE JR.
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Credential | LDO
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Telephone | 770-402-1175
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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