Provider Demographics
NPI:1093777260
Name:COMMONWEATLH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEATLH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:KING & QUEEN COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
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 8
Mailing Address - Street 2:
Mailing Address - City:KING AND QUEEN COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23085-0008
Mailing Address - Country:US
Mailing Address - Phone:804-758-2381
Mailing Address - Fax:804-758-4828
Practice Address - Street 1:167 COURTHOUSE LANDING ROAD
Practice Address - Street 2:
Practice Address - City:KING AND QUEEN COURTHOUSE
Practice Address - State:VA
Practice Address - Zip Code:23085-0008
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
VA1093777260OtherHUMANA GOLD CHOICE
VA266547OtherANTHEM
VA41162OtherOPTIMA
VA004975642Medicaid
VA165372OtherDORAL
VA41162OtherSENTARA
VA41162OtherOPTIMA
VA=========OtherVA PREMIER
VA41162OtherSENTARA
VA600000211Medicare ID - Type UnspecifiedRAILROAD