Provider Demographics
NPI:1316976699
Name:COFFEE COUNTY BOARD OF HEALTH
Entity type:Organization
Organization Name:COFFEE COUNTY BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSO
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-338-5263
Mailing Address - Street 1:1003 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2123
Mailing Address - Country:US
Mailing Address - Phone:912-389-4586
Mailing Address - Fax:913-389-4590
Practice Address - Street 1:1003 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2123
Practice Address - Country:US
Practice Address - Phone:912-389-4586
Practice Address - Fax:913-389-4590
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COFFEE COUNTY BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-30
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000808387AMedicaid
GA000955171AMedicaid
GA000955171AMedicaid
GAFLU127Medicare ID - Type UnspecifiedCOUNTY FLU BILLING #