Provider Demographics
NPI:1598130544
Name:BLUE RIDGE IN BROOKVIEW HOUSE LLC
Entity Type:Organization
Organization Name:BLUE RIDGE IN BROOKVIEW HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-358-5200
Mailing Address - Street 1:2700 N 29TH AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-1520
Mailing Address - Country:US
Mailing Address - Phone:786-358-5200
Mailing Address - Fax:786-664-3311
Practice Address - Street 1:510 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340-3620
Practice Address - Country:US
Practice Address - Phone:864-489-3101
Practice Address - Fax:864-489-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility