Provider Demographics
NPI:1669178430
Name:BLUE RIDGE FAMILY MEDICINE
Entity type:Organization
Organization Name:BLUE RIDGE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:276-686-4007
Mailing Address - Street 1:306 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368-3269
Mailing Address - Country:US
Mailing Address - Phone:276-686-4007
Mailing Address - Fax:
Practice Address - Street 1:445 GIENOW RD
Practice Address - Street 2:
Practice Address - City:RURAL RETREAT
Practice Address - State:VA
Practice Address - Zip Code:24368-3210
Practice Address - Country:US
Practice Address - Phone:276-686-4007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017597520001Medicaid