Provider Demographics
NPI:1477636728
Name:COMMONWEALTH OF VIRGINIA STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE DEPARTMENT OF HEALTH
Other - Org Name:CENTRAL VIRGINIA CHILD DEVELOPMENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRICELAND
Authorized Official - Suffix:
Authorized Official - Credentials:RN PNP
Authorized Official - Phone:434-947-2030
Mailing Address - Street 1:PO BOX 11768
Mailing Address - Street 2:CHILD DEVELOPMENT CLINIC
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24506-1768
Mailing Address - Country:US
Mailing Address - Phone:434-947-2030
Mailing Address - Fax:434-947-2389
Practice Address - Street 1:1900 THOMSON DR
Practice Address - Street 2:CHILD DEVELOPMENT CLINIC
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1009
Practice Address - Country:US
Practice Address - Phone:434-947-2030
Practice Address - Fax:434-947-2389
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA003374OtherANTHEM
VA004975111OtherVIRGINIA PREMIER
VA18765OtherOPTIMA
VA61176OtherCARENET
VA004975111Medicaid
VAC08759Medicare PIN