Provider Demographics
NPI:1114015716
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:SOUTHWEST VIRGINIA CARE CONNECTION FOR CHILDREN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OFFICE OF FAMILY HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER-HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-864-7170
Mailing Address - Street 1:15068 LEE HWY
Mailing Address - Street 2:SUITE 900
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4263
Mailing Address - Country:US
Mailing Address - Phone:276-645-4900
Mailing Address - Fax:276-645-4913
Practice Address - Street 1:15068 LEE HWY
Practice Address - Street 2:SUITE 900
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-4263
Practice Address - Country:US
Practice Address - Phone:276-645-4900
Practice Address - Fax:276-645-4913
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE BD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004976550Medicaid