Provider Demographics
NPI:1528029675
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:KING WILLIAM 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 155
Mailing Address - Street 2:
Mailing Address - City:KING WILLIAM
Mailing Address - State:VA
Mailing Address - Zip Code:23086-0155
Mailing Address - Country:US
Mailing Address - Phone:804-758-2381
Mailing Address - Fax:804-758-4828
Practice Address - Street 1:172 COURTHOUSE LANE
Practice Address - Street 2:
Practice Address - City:KING WILLIAM
Practice Address - State:VA
Practice Address - Zip Code:23086-0155
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:2006-03-29
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
VA1528029675OtherHUMANA GOLD CHOICE
VA266548OtherANTHEM
VA41163OtherOPTIMA
VI41163OtherSENTARA
VA99999999999OtherDORAL
VA004975651Medicaid
VA1528029675OtherHUMANA GOLD CHOICE
VA=========OtherCARENET
VA1528029675OtherHUMANA GOLD CHOICE
VA=========OtherCARENET