Provider Demographics
NPI:1205215001
Name:BLUE RIDGE OPTICAL
Entity Type:Organization
Organization Name:BLUE RIDGE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:540-776-9722
Mailing Address - Street 1:110 PROFESSIONAL PARK DR SE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6735
Mailing Address - Country:US
Mailing Address - Phone:540-552-4588
Mailing Address - Fax:540-552-4612
Practice Address - Street 1:110 PROFESSIONAL PARK DR SE
Practice Address - Street 2:SUITE 6
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6735
Practice Address - Country:US
Practice Address - Phone:540-552-4588
Practice Address - Fax:540-552-4612
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE RIDGE OPTICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11011002026156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty