Provider Demographics
NPI:1407368608
Name:BLUE RIDGE HEALTHCARE MONTGOMERY LLC
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MONTGOMERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADMINISTRATOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ADMINISTRATOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-281-6826
Mailing Address - Street 1:4490 VIRGINIA LOOP RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-3448
Mailing Address - Country:US
Mailing Address - Phone:334-281-6826
Mailing Address - Fax:334-281-6901
Practice Address - Street 1:4490 VIRGINIA LOOP RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-3448
Practice Address - Country:US
Practice Address - Phone:334-281-6826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility