Provider Demographics
NPI:1972206415
Name:BLUE RIDGE EATING DISORDER TREATMENT CENTER LLC
Entity type:Organization
Organization Name:BLUE RIDGE EATING DISORDER TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-718-8800
Mailing Address - Street 1:213 BLUE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAYLORSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18353-8131
Mailing Address - Country:US
Mailing Address - Phone:570-718-8800
Mailing Address - Fax:
Practice Address - Street 1:213 BLUE RIDGE RD
Practice Address - Street 2:
Practice Address - City:SAYLORSBURG
Practice Address - State:PA
Practice Address - Zip Code:18353-8131
Practice Address - Country:US
Practice Address - Phone:732-887-7136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-23
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health