Provider Demographics
NPI:1689709479
Name:BLUE RIDGE CHIROPRACTIC CLINIC P.C.
Entity Type:Organization
Organization Name:BLUE RIDGE CHIROPRACTIC CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MALAVOLTI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:276-227-0414
Mailing Address - Street 1:1135 W LEE HWY
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1525
Mailing Address - Country:US
Mailing Address - Phone:276-227-0414
Mailing Address - Fax:276-227-0416
Practice Address - Street 1:1135 W LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1525
Practice Address - Country:US
Practice Address - Phone:276-227-0414
Practice Address - Fax:276-227-0416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty