Provider Demographics
NPI:1053584151
Name:BLUE RIDGE VISION ASSOCIATES. PA
Entity type:Organization
Organization Name:BLUE RIDGE VISION ASSOCIATES. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:864-877-3031
Mailing Address - Street 1:312 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-1521
Mailing Address - Country:US
Mailing Address - Phone:864-877-3031
Mailing Address - Fax:
Practice Address - Street 1:312 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1521
Practice Address - Country:US
Practice Address - Phone:864-877-3031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0125740001Medicare NSC