=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982380036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2023
-----------------------------------------------------
Last Update Date | 01/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 CLARKESVILLE PLZ
-----------------------------------------------------
City | CLARKESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30523-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-334-1856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3248 CLARKS BRIDGE RD
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30506-3722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-334-1856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACTED MANAGING EMPLOYEE
-----------------------------------------------------
Name | MS. TRUSHNA RAO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-334-1856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------