Provider Demographics
NPI:1649206814
Name:BLUE RIDGE EYE CARE ASSOCIATES PLLC
Entity Type:Organization
Organization Name:BLUE RIDGE EYE CARE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:TUTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-236-4171
Mailing Address - Street 1:800 E STUART DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2321
Mailing Address - Country:US
Mailing Address - Phone:276-236-4171
Mailing Address - Fax:276-236-0909
Practice Address - Street 1:800 E STUART DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2321
Practice Address - Country:US
Practice Address - Phone:276-236-4171
Practice Address - Fax:276-236-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001546152W00000X, 152W00000X
VA0618000354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1649206814OtherGROUP NPI NUMBER
C08597Medicare PIN
VA1649206814OtherGROUP NPI NUMBER