Provider Demographics
NPI:1083675474
Name:VIRGINIA DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:VIRGINIA DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-926-4979
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-0768
Mailing Address - Country:US
Mailing Address - Phone:276-926-4979
Mailing Address - Fax:276-926-4426
Practice Address - Street 1:334 BRUSH CREEK ROAD
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228-0768
Practice Address - Country:US
Practice Address - Phone:276-926-4979
Practice Address - Fax:276-926-4426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA370009593OtherRAILROAD MEDICARE
VA370009593OtherRAILROAD MEDICARE