Provider Demographics
NPI:1508951567
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:HENRICO HEALTH DEPARTMENT - EAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-501-4953
Mailing Address - Street 1:3810 NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23223-4848
Mailing Address - Country:US
Mailing Address - Phone:804-652-3186
Mailing Address - Fax:804-501-4588
Practice Address - Street 1:3810 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23223-4848
Practice Address - Country:US
Practice Address - Phone:804-652-3186
Practice Address - Fax:804-501-4588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA68428Medicaid
VA072212OtherANTHEM
VA10001587Medicaid
VA4975588Medicaid
VA4975588Medicaid
VA600000018Medicare PIN