Provider Demographics
NPI:1013478411
Name:BLUE RIDGE SNF OPERATIONS LLC
Entity Type:Organization
Organization Name:BLUE RIDGE SNF OPERATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SHIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:IDELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-565-7391
Mailing Address - Street 1:7523 MAIN ST # 39
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-7652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 LANDMARK DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171-9401
Practice Address - Country:US
Practice Address - Phone:276-694-4230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility