Provider Demographics
NPI:1063689834
Name:BLUE RIDGE OPTICAL
Entity Type:Organization
Organization Name:BLUE RIDGE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/LICENSED OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-776-9722
Mailing Address - Street 1:33 BRITISH WOODS DR
Mailing Address - Street 2:1960 ELECTRIC ROAD
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8267
Mailing Address - Country:US
Mailing Address - Phone:540-992-6797
Mailing Address - Fax:
Practice Address - Street 1:33 BRITISH WOODS DR
Practice Address - Street 2:1960 ELECTRIC ROAD
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-8267
Practice Address - Country:US
Practice Address - Phone:540-992-6797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE RIDGE OPTICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101 000964332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAOP2378OtherEYEMED VISION CARE