Provider Demographics
NPI:1356587331
Name:BLUE RIDGE INDEPENDENT LIVING CENTER INC
Entity type:Organization
Organization Name:BLUE RIDGE INDEPENDENT LIVING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MICHALSKI-KARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-342-1231
Mailing Address - Street 1:1502 WILLIAMSON RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-5100
Mailing Address - Country:US
Mailing Address - Phone:540-342-1231
Mailing Address - Fax:540-342-9505
Practice Address - Street 1:1502 WILLIAMSON RD NE STE B
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-5100
Practice Address - Country:US
Practice Address - Phone:540-342-1231
Practice Address - Fax:540-342-9505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0087429103Medicaid
VA0087419724Medicaid
VA0154630583Medicaid