Provider Demographics
NPI:1598941304
Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
Other - Org Name:AFFINITY FACE AND BODY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP-CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:FRITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-580-5546
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:VALDESE
Mailing Address - State:NC
Mailing Address - Zip Code:28690-0700
Mailing Address - Country:US
Mailing Address - Phone:828-874-3160
Mailing Address - Fax:828-874-2820
Practice Address - Street 1:720 MALCOLM BLVD
Practice Address - Street 2:
Practice Address - City:VALDESE
Practice Address - State:NC
Practice Address - Zip Code:28690-2872
Practice Address - Country:US
Practice Address - Phone:828-874-3160
Practice Address - Fax:828-874-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty