Provider Demographics
NPI:1346449451
Name:BLUE RIDGE NURSING, LLC
Entity Type:Organization
Organization Name:BLUE RIDGE NURSING, LLC
Other - Org Name:WILLOW TREE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BELLONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-625-1502
Mailing Address - Street 1:10123 ALLIANCE RD STE 240
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4714
Mailing Address - Country:US
Mailing Address - Phone:410-625-1502
Mailing Address - Fax:410-625-7574
Practice Address - Street 1:1263 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-4384
Practice Address - Country:US
Practice Address - Phone:304-725-6575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility