Provider Demographics
NPI:1093759706
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:WYTHE COUNTY HEALTH DEPT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:H
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-781-7450
Mailing Address - Street 1:290 S 6TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2511
Mailing Address - Country:US
Mailing Address - Phone:276-228-5507
Mailing Address - Fax:276-228-3392
Practice Address - Street 1:290 S 6TH ST STE 300
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2511
Practice Address - Country:US
Practice Address - Phone:276-228-5507
Practice Address - Fax:276-228-3392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-15
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004976037Medicaid
VA600936270Medicare PIN
VA004976037Medicaid
VAC08868Medicare PIN
VA00V648C68Medicare PIN
VA00V647C68Medicare PIN
VA005631C68Medicare PIN