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General NPI Number Information
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NPI Number | 1952390221
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE PODIATRY ASSOCIATES
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Dates
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Enumeration Date | 10/19/2005
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Last Update Date | 11/22/2010
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Provider Practice Location Address
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Address Line | 390 S MAIN ST STE 103
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City | ROCKY MOUNT
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State | VA
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Zip | 24151-1767
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Country | US
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Telephone | 540-483-7933
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Fax | 540-463-9454
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Provider Business Mailing Address
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Address Line | PO BOX 4205
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City | EDEN
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State | NC
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Zip | 27289-4205
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Country | US
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Telephone | 336-623-4545
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Fax | 206-333-1892
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN LARRY CLEMENTS
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Credential | D.P.M
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Telephone | 540-885-8891
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 0103000371
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 0103300877
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 0103000391
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License Number State | VA
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