Provider Demographics
NPI:1871502880
Name:BLUE RIDGE NEUROSCIENCE CENTER, P.C.
Entity Type:Organization
Organization Name:BLUE RIDGE NEUROSCIENCE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROYSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-392-2887
Mailing Address - Street 1:2 SHERIDAN SQ
Mailing Address - Street 2:STE 200
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7399
Mailing Address - Country:US
Mailing Address - Phone:423-392-2887
Mailing Address - Fax:423-246-8278
Practice Address - Street 1:2 SHERIDAN SQ
Practice Address - Street 2:STE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7399
Practice Address - Country:US
Practice Address - Phone:423-392-2887
Practice Address - Fax:423-246-8278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3386406Medicare PIN
TN4763690001Medicare NSC