Provider Demographics
NPI:1134396898
Name:BLUE RIDGE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:BLUE RIDGE CHIROPRACTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:334-514-7327
Mailing Address - Street 1:1504 PRAIRIE LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3477
Mailing Address - Country:US
Mailing Address - Phone:334-318-1427
Mailing Address - Fax:
Practice Address - Street 1:2412 US HWY 231
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092
Practice Address - Country:US
Practice Address - Phone:334-514-7327
Practice Address - Fax:334-514-7328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty