Provider Demographics
NPI:1992767131
Name:COMMONWEATLH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEATLH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-758-2381
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-0663
Mailing Address - Country:US
Mailing Address - Phone:804-758-2381
Mailing Address - Fax:804-758-4828
Practice Address - Street 1:6882 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-0663
Practice Address - Country:US
Practice Address - Phone:804-758-2381
Practice Address - Fax:804-758-4828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975529Medicaid
VA41161OtherSENTARA
VA1992767131OtherHUMANA GOLD CHOICE
VA266546OtherANTHEM
VA41161OtherOPTIMA
VA=========OtherVA. PREMIER
VA004975529Medicaid
VA1992767131OtherHUMANA GOLD CHOICE
VA004975529Medicaid