Provider Demographics
NPI:1508430851
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-952-2124
Mailing Address - Street 1:509 MED TECH PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2579
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:423-952-2175
Practice Address - Street 1:1420 TUSCULUM BLVD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4279
Practice Address - Country:US
Practice Address - Phone:423-787-6351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty