Provider Demographics
NPI:1063457398
Name:BACON COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:BACON COUNTY BOARD OF HEALTH
Other - Org Name:
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:912-427-2042
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510-0116
Mailing Address - Country:US
Mailing Address - Phone:912-632-4712
Mailing Address - Fax:912-632-7834
Practice Address - Street 1:101 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510-2540
Practice Address - Country:US
Practice Address - Phone:912-632-4712
Practice Address - Fax:912-632-7834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000442967DMedicaid
GA000052027DMedicaid
GA000453098CMedicaid
GA000584702AMedicaid
GA000457784CMedicaid
GA000584702AMedicaid
GA000457784CMedicaid
GAFLU120Medicare ID - Type UnspecifiedCOUNTY FLU BILLING #