Provider Demographics
NPI:1639192594
Name:BLUE RIDGE OPTICAL
Entity Type:Organization
Organization Name:BLUE RIDGE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:VA, LICENSEDOPTICIAN
Authorized Official - Phone:540-776-9722
Mailing Address - Street 1:1960 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1621
Mailing Address - Country:US
Mailing Address - Phone:540-776-9722
Mailing Address - Fax:504-776-5119
Practice Address - Street 1:1960 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1621
Practice Address - Country:US
Practice Address - Phone:540-776-9722
Practice Address - Fax:504-776-5119
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE RIDGE OPTICAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA452898OtherANTHEM
VA92-8062-6Medicaid
VA92-8062-6Medicaid