Provider Demographics
NPI:1902415730
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:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-776-9722
Mailing Address - Street 1:1960 ELECTRIC RD STE B
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1601
Mailing Address - Country:US
Mailing Address - Phone:540-776-9722
Mailing Address - Fax:540-627-5418
Practice Address - Street 1:4910 VALLEY VIEW BLVD NW STE 110
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-2022
Practice Address - Country:US
Practice Address - Phone:540-632-0900
Practice Address - Fax:540-627-5418
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE RIDGE OPTICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty