Provider Demographics
NPI:1275532426
Name:BLUE RIDGE OF RALEIGH LLC
Entity Type:Organization
Organization Name:BLUE RIDGE OF RALEIGH LLC
Other - Org Name:BLUE RIDGE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4004
Mailing Address - Street 1:3830 BLUE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4319
Mailing Address - Country:US
Mailing Address - Phone:919-781-4900
Mailing Address - Fax:919-571-2583
Practice Address - Street 1:3830 BLUE RIDGE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4319
Practice Address - Country:US
Practice Address - Phone:919-781-4900
Practice Address - Fax:919-571-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340613WWMedicaid
NC340613WWMedicaid