Provider Demographics
NPI:1780074286
Name:BLUE RIDGE ON THE MOUNTAIN LLC
Entity type:Organization
Organization Name:BLUE RIDGE ON THE MOUNTAIN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-358-5200
Mailing Address - Street 1:417 MOUNTAIN TRACE RD
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-6779
Mailing Address - Country:US
Mailing Address - Phone:828-631-1600
Mailing Address - Fax:828-631-1648
Practice Address - Street 1:417 MOUNTAIN TRACE RD
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-6779
Practice Address - Country:US
Practice Address - Phone:828-631-1600
Practice Address - Fax:828-631-1648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC345302Medicare Oscar/Certification