Provider Demographics
NPI:1689135576
Name:BLUE RIDGE MOUNTAIN OPHTHALMOLOGY LLC
Entity Type:Organization
Organization Name:BLUE RIDGE MOUNTAIN OPHTHALMOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-279-6092
Mailing Address - Street 1:266 ORVIN LANCE DR STE 5
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-8054
Mailing Address - Country:US
Mailing Address - Phone:478-279-6092
Mailing Address - Fax:
Practice Address - Street 1:266 ORVIN LANCE DR STE 5
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-8054
Practice Address - Country:US
Practice Address - Phone:478-279-6092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery