=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336620756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE HOME CARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2018
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 E LOOCKERMAN ST STE 211
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19901-7347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-397-8211
-----------------------------------------------------
Fax | 302-510-4627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 E LOOCKERMAN ST STE 211
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19901-7347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-397-8211
-----------------------------------------------------
Fax | 302-510-4627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TUNJI ISAAC OGUNMOLA
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 215-457-4950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225CX0006X
-----------------------------------------------------
Taxonomy Name | Orientation and Mobility Training Rehabilitation Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------