Provider Demographics
NPI:1154787141
Name:BLUE RIDGE BY THE LAKE LLC
Entity type:Organization
Organization Name:BLUE RIDGE BY THE LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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 1:2700 N 29TH AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-1520
Mailing Address - Country:US
Mailing Address - Phone:786-358-5200
Mailing Address - Fax:
Practice Address - Street 1:1100 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-6224
Practice Address - Country:US
Practice Address - Phone:727-345-9331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility