Provider Demographics
NPI:1477572626
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:CHESTERFIELD HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-748-1630
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-0002
Mailing Address - Country:US
Mailing Address - Phone:804-748-1743
Mailing Address - Fax:804-751-4497
Practice Address - Street 1:9501 LUCY CORR CIR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6697
Practice Address - Country:US
Practice Address - Phone:804-748-1743
Practice Address - Fax:804-751-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975189Medicaid
4975189OtherVIRGINIA PREMIER HEALTH
VA12470OtherCARENET/SOUTHERN HEALTH
VA266457OtherANTHEM BLUE CROSS/BSHIELD
41174OtherOPTIMA FAMILY CARE
4975189OtherVIRGINIA PREMIER HEALTH
600699119Medicare PIN
VA266457OtherANTHEM BLUE CROSS/BSHIELD
VA12470OtherCARENET/SOUTHERN HEALTH
600000034Medicare PIN