Provider Demographics
NPI:1043243876
Name:BULLOCH COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:BULLOCH COUNTY BOARD OF HEALTH
Other - Org Name:BULLOCH WELLNESS CENTER
Other - Org Type:Doing Business As
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:9123-388-5263
Mailing Address - Street 1:3 W ALTMAN ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5212
Mailing Address - Country:US
Mailing Address - Phone:912-764-2402
Mailing Address - Fax:912-764-5561
Practice Address - Street 1:3 W ALTMAN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5212
Practice Address - Country:US
Practice Address - Phone:912-764-2402
Practice Address - Fax:912-764-5561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000808398AMedicaid
GA000808398BMedicaid
GAFLU122Medicare ID - Type UnspecifiedCOUNTY FLU BILLING #