Provider Demographics
NPI:1366462137
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-748-1630
Mailing Address - Street 1:3908 OLD BUCKINGHAM RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-5753
Mailing Address - Country:US
Mailing Address - Phone:804-598-5680
Mailing Address - Fax:804-598-5688
Practice Address - Street 1:3908 OLD BUCKINGHAM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-5753
Practice Address - Country:US
Practice Address - Phone:804-598-5680
Practice Address - Fax:804-598-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
41199OtherOPTIMA FAMILY CARE
VA004975847Medicaid
12499OtherCARENET/SOUTHERN HEALTH
VA266459OtherANTHEM BLUE CROSS BSHIELD
4975847OtherVIRGINIA PREMIER HEALTH
990000019Medicare PIN
VA004975847Medicaid
4975847OtherVIRGINIA PREMIER HEALTH
41199OtherOPTIMA FAMILY CARE