Provider Demographics
NPI:1639132137
Name:COMMONWEATLH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEATLH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:NORTHUMBERLAND 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 69
Mailing Address - Street 2:
Mailing Address - City:HEATHSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22473-0069
Mailing Address - Country:US
Mailing Address - Phone:804-758-2381
Mailing Address - Fax:804-758-4828
Practice Address - Street 1:6373 NORTHUMBERLAND HWY.
Practice Address - Street 2:SUITE B
Practice Address - City:HEATHSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22473-0069
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:2006-04-07
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
VA004975782Medicaid
VA41166OtherOPTIMAHEALTH
VA266552OtherANTHEM
VA41166OtherVETRI
VA1639132137OtherHUMANA GOLD CHOICE
VA41166OtherVETRI
VA=========OtherVA PREMIER
VA=========OtherCARENET
VA266552OtherANTHEM