Provider Demographics
NPI:1912117367
Name:BLUE RIDGE NUTRITION SERVICES, INC.
Entity Type:Organization
Organization Name:BLUE RIDGE NUTRITION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:W
Authorized Official - Last Name:KARSCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-939-8720
Mailing Address - Street 1:3538 HABERSHAM AT NORTHLAKE
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4009
Mailing Address - Country:US
Mailing Address - Phone:770-939-8720
Mailing Address - Fax:770-938-7288
Practice Address - Street 1:3538 HABERSHAM AT NORTHLAKE
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4009
Practice Address - Country:US
Practice Address - Phone:770-939-8720
Practice Address - Fax:770-938-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106901332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000699311AMedicaid
GA000699311AMedicaid